Environmental Health and Health Effects of Environmental Change

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Library of Congress Cataloging-in-Publication Data Jacobsen, Kathryn H.

Introduction to global health / Kathryn H. Jacobsen. -- 2nd ed. p. ;cm.

fucludes bibliographical references and index. ISBN 978-1'4496-4825-1 (pbk.) -- ISBNI-4496-4825-8 (pbk.) I. Title. [DNLM: I. World Health. 2. Communicable Disease Control. 3. Health Transition.

4. Internationality. WA 530.1] 362.1--dc23

6048

Printed in the United States of America 17 16 15 14 13 10 9 8 7 6 5 4 3

2012039129

1.1 Defining Health .................................. 1 1.2 Medicine and Public Health ........................ 2 1.3 The Emergence of Global Health ................... .4 1.4 Health Transitions in the 20th Century ................ 4

1.4.A Demographic Transitions ..................... 6 l.4.B Epidemiologic Transitions .................... 7 L4.C Nutrition Transitions ......................... 9

1.5 Risk Factors ................................... 10 1.6 Prevention ..................................... 13 1.7 Careers in Global Health .......................... 15 1.8 Discussion Questions ............................ 16 References ......................................... 17

2.1 The Importance of Health Metrics .................. 19 2.2 Measuring Health and Disease ..................... 21

2.2.A Vital Statistics and Demography .............. 21 2.2.B Measuring Mortality ........................ 21

iii

iv CONTENTS

2.2.C Measuring Morbidity ....................... 24 2.2.D Measuring Disability ....................... 25 2.2.E Quantifying Risk Factors .................... 26 2.2.F Health Systems Performance ................. 28

2.3 Classifying Disease .............................. 29 2.3.A Infectious and Parasitic Diseases .............. 30 2.3.B Noncommunicable Diseases ................. 31 2.3.C Neuropsychiatric Disorders .................. 33 2.3.D Injuries .................................. 34

2.4 Sources of Health Information ..................... 37 2.5 Discussion Questions ............................ 39 References ......................................... 39

Chapter 3-Research and Global Health ........... ......... . 41

3.1 The Importance of Global Health Research ........... 41 3.2 The Research Process ............................ 42 3.3 Observational Study Designs ..................... .43

3.3.A Prevalence Surveys ........................ 43 3.3.B Case Series ............................... 44 3.3.C Case-Control Studies ...................... .44 3.3.D Cohort Studies ........................... .47

3.4 Experimental Studies ............................ 50 3.5 Research Ethics ................................. 52 3.6 Synthesis Studies ............................... 54

3.6.A Correlational Studies ....................... 54 3.6.B Systematic Reviews and Meta-Analyses ........ 55 3.6.C Forecasting and Modeling ................... 56

3.7 Interpreting Statistics ............................ 56 3.8 Critical Reading ................................ 59 3.9 Evidence-Based Global Health ..................... 61 3.10 Discussion Questions ............................ 62 References ......................................... 63

Chapter 4-Socioeconomic Determinants of Health .. ......... . 65

4.1 Social Determinants of Health ..................... 65 4.1.A Income, Wealth, and Health .................. 67 4.1.B Employment and Occupational Status .......... 69 4.1.C Literacy and Educational Level ............... 70

Contents v

4.2 Socioeconomic Indicators .................. 0 •••••• 72 4.3 Health of Vulnerable Populations ................... 77

4.3.A Race, Ethnicity, and Health .................. 77 4.3.B Immigrants ....................... 0 ••••••• 79 4.3.C Prisoners ................................. 80

4.4 Culture and Health .............................. 82 4.5 Discussion Questions , ........................... 83 References ......................................... 83

5.1 Inequalities in Child Death ........................ 87 5.2 Neonatal Mortality ............ 0 ••••••••••••••••• 88 5.3 Diarrhea ....................................... 90 5.4 Pneumonia ..................................... 94 5.5 Malaria ....................................... 96 5.6 Vaccine-Preventable Diseases ..................... 97 5.7 Undernutrition and Breastfeeding ................... 97 5.8 Global Child Health Initiatives .................... 101 5.9 The Rights of Children .......................... 104 5.10 Discussion Questions ........................... 106 References ........................................ 107

6.1 Health in Early Adulthood ....................... 109 6.2 Mental Health ................................. 109 6.3 Injuries ..................................... 0 113 6.4 Sex, Gender, and Health ......................... 115 6.5 Reproductive Health and Maternal Mortality ......... 117 6.6 Family Planning ............................... 122 6.7 Fertility ...................................... 124 6.8 Population Growth ............................. 128 6.9 Population Planning Policies ..................... 130 6.10 Discussion Questions ........................... 133 References ........................................ 134

o •• , ••••• , .137

7.1 Global Aging .................................. 137 7.2 Cardiovascular Diseases ......................... 140

vi CONTENTS

7.3 Cancer ....................................... 142 7.4 Chronic Lung Disease ........................... 147 7.5 Diabetes ...................................... 148 7.6 Sensory Impairment ............................ 148 7.7 Disability ..................................... 149 7.8 Dementia ..................................... 153 7.9 Screening and Early Detection .................... 154 7.10 Planning for Aging Populations ................... 156 7.11 Discussion Questions ........................... 159 References ........................................ 160

Chapter 8-The Environmental Context of Health ............ 163

8.1 Environmental and Occupational Health ............ 163 8.2 The Home Environment ......................... 166 8.3 Drinking Water ................................ 167 8.4 Sanitation .................................... 172 8.5 Fuel and Indoor Air QUality ...................... 176 8.6 The Work Environment ......................... 179 8.7 Toxicology ................................... 180 8.8 Communities and Environmental Health ............ 182 8.9 Discussion Questions ........................... 184 References ........................................ 185

Chapter 9-Control of Infectious Diseases .........•........• 187

9.1 Global Infectious Diseases ....................... 187 9.2 Agents of Infection ............................. 188

9.2.A Bacteria ................................ 188 9.2.B Viruses ................................. 189 9.2.C Parasites ................................ 190 9.2.D Fungi ................................... 191 9.2.E Prions .................................. 191

9.3 Exposure, Infection, and Disease .................. 192 9.4 Infectious Disease Transmission ................... 194 9.5 Diarrheal and Foodborne Diseases ................. 196 9.6 Respiratory Diseases ............................ 198 9.7 Vectorborne Diseases ........................... 200 9.8 Sexually Transmitted Infections (STIs) ............. 204 9.9 Neglected Tropical Diseases (NTDs) ............... 205

Contents Vll

9.10 OtherInfectious Diseases ....................... 210 9.11 Infection Control and Prevention ................. 210

9.11.A Behavior Change ......... " ............ 210 9.11.B Environmental Control. .................. 213 9.11.C Vaccination ............................ 214 9.11.D Drug Therapy .......................... 215 9.11.E Surveillance ........................... 216 9.11.F Elimination and Eradication ............... 217

9.12 Discussion Questions .......................... 218 References ........................................ 219

10.1 Comparison of HI V, TB, and Malaria .............. 221 10.2 HIV/AIDS .................................... 221 10.3 Tuberculosis (TB) .............................. 231 10.4 Malaria ...................................... 236 10.5 Influenza ..................................... 242 10.6 Other Global Infectious Disease Initiatives .......... 244 10.7 Discussion Questions ........................... 244 References ......................................... 245

11.1 Essential Nutrients ............................. 249 11.2 Macronutrients ................................ 249 11.3 Micronutrients ................................. 254 11.4 Measuring Nutritional Status ..................... 257 11.5 Undernutrition ................................. 258 11.6 Hunger and Food Security ....................... 260 11.7 Micronutrient Deficiencies ....................... 263

11.7.A Vitamin A Deficiency (VAD) .............. 264 11. 7.B Iodine Deficiency Disorders (IDD) .......... 265 11.7.C Iron Deficiency Anemia (IDA) .............. 265 Il.7.D Zinc Deficiency ......................... 267 11.7.E Preventing Micronutrient Deficiencies ....... 267

1l.8 Overweight and Obesity ......................... 268 11.9 Discussion Questions ........................... 272 References ......................................... 273

viii CONTENTS

Chapter 12-Global Health Payers and Players ............... 277

12.1 Health Systems ................................ 277 12.2 Personal Healthcare Costs ....................... 280 12.3 Paying for Global Public Health ................... 283

12.3.A Local and National Government Funds ....... 284 . 12.3.B Bilateral Aid ............................ 285

12.3.C The World Bank and IMF ................. 286 12.3.D Private Foundations ...................... 289 12.3.E Businesses .............................. 290 12.3.F Personal Donations ....................... 290

12.4 Types of Global Health Programs ................. 294 12.5 Implementing Health Programs ................... 295

12.5.A National and Local Governments ............ 296 12.5.B United Nations Agencies .................. 298 12.5.C International Cooperation .................. 299 12.5.D Global Health Partnerships ................. 301 12.5.E Nongovernmental Organizations (NGOs) ..... 302 12.5.F International Committee of the Red Cross ..... 304 12.5.G International Businesses ................... 305

12.6 Discussion Questions ........................... 305 References ......................................... 306

Chapter 13-Globalization and Health ...................... 309

13.1 Globalization and Global Health ................. 309 13.2 Urbanization and Health ........................ 310 13.3 Emerging Infectious Diseases .................... 316 13.4 Nutrition and Food Safety ....................... 319 13.5 Bioterrorism and Security ....................... 322 13.6 Global Environmental Change and Health .......... 325 13.7 Discussion Questions .......................... 330 References ........................................ 331

Chapter 14-Health, Human Rights, and Humanitarian Aid .... 335

14.1 Health and Human Rights ....................... 335 14.2 Access to Health .............................. 338

14.2.A Access to Health Care ................... 340 14.2.B Access to Medication .................... 340

Contents IX

14.2.C Access to Health Technology .............. 344 14.2.D Access to Water ........................ 346

14.3 Disasters and Health ........................... 347 14.3.A Civil Conflict and War ................... 349 14.3.B Refugees and Internally Displaced People .... 350 14.3.C Postconflict Areas ....................... 352 14.3.D Natural Disasters ....................... 352

14.4 Emergency Preparedness and Response ............ 356 14.5 Discussion Questions .......................... 357 References ........................................ 357

15.1 Global Health Successes ........................ 361 15.2 Millennium Development Goals .................. 362 15.3 Current Priorities .............................. 366 15.4 The Price of Global Health ...................... 370

lS.4.A Cost-Effectiveness ...................... 371 15.4.B Sustainability .......................... 373 15.4.C Costs ofInaction ........................ 374

15.5 Beyond Cost-Effectiveness ...................... 374 15.6 Discussion Questions .......................... 376 References ........................................ 376

On June 16, 2006, Bm Gates, founder of Microsoft and the richest man in the world, made headlines when he announced his intention to scale back his work at Microsoft to devote more time to the charitable foundation he had co-founded with his Melinda.! Ten later, even bigger head- lines were made when Warren Buffett, the second wealthiest man in the world, made a surprising announcement-he was handing over most of his fortune to Bill Gates. 2 More precisely, the bulk of his accumulated wealth was going to the Bill & Melinda Gates Foundation, which focuses primarily on improving global health. As a result, the Bill & Melinda Gates Foundation, the largest philanthropic foundation in the world even prior to Buffett's generous donation, doubled in value to more than $60 billion.

What would inspire the wealthiest men in the world to develop such a passion for one cause? They had become aware of an awful reality: Every year, several million children die of diseases that are completely prevent- able. In an address to the World Health Assembly, the governing body of the World Health Organization, Bill Gates described the awakening of his philanthropic impulse:

I first learned about these tragic health inequities some years ago when I was reading an article about diseases in the developing world. It showed that more than half a million children die every year from "rotavirus." I thought, "'Rotavirus?' -I've never even heard of it. How could I never have heard of something that kills half a million children every yearl?"

I read further and learned that millions of children were dying from diseases that had essentially been eliminated in the United States. Melinda and I had assumed that if there were vaccines and

xii PREFACE

treatments that could save lives, governments would be doing everything they could to get them to the people who needed them. But they weren't. We couldn't escape the brutal conclusion that-in our world today-some lives are seen as worth saving and others are not. We said to ourselves: "This can't be true. But if it is true, it deserves to be the priority of our giving.,,3

Gates ended his speech with a call to action:

I am optimistic that in the next decade, people's thinking will evolve on the question of health inequity. People will finally accept that the death of a child in the developing world is just as tragic as the death of a child in the developed world. And the expanding capacities of science will give us the power to act on that conviction. When we do, we have a chance to make sure that all people, no matter what country they live in, will have the preventive care, vaccines, and treatments they need to live a healthy life. I believe we can do this-and if we do, it will be the best thing humanity has ever done.

Since global health has become the object of attention for Bill Gates, Warren Buffet, and other influential world leaders, it has, not surpris- ingly, also developed rapidly as an academic and professional field. The Consortium of Universities for Global Health (CUGH), founded in 2009, reports that the number of undergraduate and graduate students at large universities majoring in global health studies doubled in just the 3 years from 2006 to 2009.4 By 2009, all of the top 50 liberal arts colleges ranked by U.S. News & World Report were offering at least one course in global health or public health, and nearly half offer a major, concentration, or other program of study in global or public health. 5 The American Association of Medical Colleges reports that nearly one-third of medical students graduat- ing in 2011 completed a global health experience during medical school,6 up from only about 15% of medical students in the 1990s and less than 10% in the 1980s.7 The trend toward higher enrollment in global health courses, programs, and experiences is expected to continue in the coming years.

Global health is not just about health in low-income countries; it is about common health problems faced by the human population as a whole. In today's interconnected world, our own experiences of health and well-being are literally inseparable from everyone else's. We cannot prevent the birds and insects that carry influenza, West Nile virus, and other infectious agents

Preface xiii

from flying over national borders, just as we cannot inspect every imported banana or bean sprout for possible contaminants. The complexities of infec- tious disease, mental health, injuries, reproductive health, aging, nutrition, and other health-related issues require us to think beyond our households and immediate communities to regional, national, and global levels. Global health is relevant in the workplace too. No matter what the occupation- business, public service, education, medicine, religion, engineering, social work, community development, agriculture, manufacturing, or anything else-workers are involved in activities that intentionally or unintention- ally impact human and environmental health close to home and around the world.

The study of global health helps us to make a positive difference in the world. It helps us to understand the causes and consequences of health concerns; to make connections between economics, politics, biology, medi- cine, sociology, psychology, and a host of other fields; to learn from others about effective and ineffective responses to critical problems; and, more generally, to make sense of the complexities of 21st-century life. A solid foundation in global health allows global citizens to assess their own vul- nerabilities and health risks, to make informed choices about their career paths, and to make wise decisions about how to use their time and resources. Studying global health is an opportunity to explore important questions about how the world works, to develop intellectual and practical skills, and to engage with real-world challenges close to home and across the planet. This second edition of Introduction to Global Health provides a starting point for achieving those educational and personal goals,

1. Markoff J, Lohr S. Gates to cede software reins. New York Times. 2006 Jun 16. 2. O'Brien TL, Saul S. Buffett to give bulk of his fortune to Gates charity. New York Times.

2006 Jun 26. 3. Gates B. Address to the 2005 World Health Assembly. Geneva; 2005 May 16. 4. Saving lives: Universities transforming global health. CUGH; 2009. 5. Hill DR, Ainsworth RM, Partap U. Teaching global public health in the undergraduate

liberal arts: a survey of 50 colleges. Am J Trap Med Hyg. 2012;87:11-15. 6. Medical school graduation questionnaire: 2011 all schools summary report.

Washington, DC: AAMC; 2011. 7, Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health

in medical education: a call for more training and opportunities. Acad Med. 2007;82: 226-230.

Global health as a field of study has matured a great deal since the first edition of this textbook was published, and the second edition of Introduction to Global Health has been updated to reflect the current state of the field (including, of course, all new statistics).

The first unit of the book focuses on the foundations of global health as an academic and professional discipline.

e Chapter 1 has a new emphasis on health transitions, which are the demographic, epidemiologic, and nutritional changes that occur in populations undergoing socioeconomic development.

s Chapter 2 is a new overview of global health metrics, the numbers that form the basis for evidence-based policy and practice. Chapter 2 also introduces the eight countries that are highlighted throughout the book as examples of the health profiles in different world regions and income strata: the United States, South Korea (the Republic of Korea), Poland, Brazil, China, India, Kenya, and Sierra Leone.

s Chapter 3 provides a brief overview of global health research methods. This chapter gives readers the tools to find, read, understand, and apply health research articles and reports, including the more than 550 sources cited in the textbook. Research skills allow readers to peruse the most up-to-date primary source material, an essential skill for a field as dynamic as global health.

@ Chapter 4 is about the social determinants of health-the social, cultural, economic, political, and related factors that influence health status.

xvi NEW TO THIS EDITION

The second unit is about global health across the lifespan.

• Chapter 5 is an expanded chapter on infant and child health that emphasizes ways to prevent the most common causes of neonatal and pediatric death worldwide.

• Chapter 6 is a new chapter on the health of young adults that discusses mental health, injuries, maternal mortality, family planning, and other important global issues.

• Chapter 7 is a new chapter on chronic noncommunicable diseases (NCDs) and aging that highlights the diseases that are the most common causes of death and disability among older adults in every region of the world. These include cardiovascular diseases, cancer, chrQnic lung disease, diabetes, and sensory impairments.

The third unit is about global health biology and the environmental context of health.

• Chapter 8 focuses on drinking water, sanitation, energy, occupational health, and other aspects of environmental health.

• Chapter 9 has a new focus on infectious disease prevention and control. Behavior change, environmental control, vaccination, drug therapy, and other methods for preventing and treating diarrheal, respiratory, vectorborne, and other infections are described.

• Chapter 10 provides an in-depth look at HIV/AIDS, tuberculosis, malaria, and influenza, with new coverage of the major initiatives working to address these global concerns.

• Chapter 11 covers the complex issues of global nutrition.

The fourth unit is about global health policy and practice.

• Chapter 12 describes the various entities that pay for and imple- ment public health programs, highlighting the many different career paths and volunteer opportunities for those with interests in global health.

• Chapter 13 is an expanded chapter that highlights several of the key emerging issues of globalization and global health, such as urbaniza- tion, emerging infectious diseases, nutrition and food safety, bioter- rorism, and global environmental change.

New to This Edition xvii

® Chapter 14 is a new chapter focusing on health and human rights, access to health, health during disasters and humanitarian emergencies, and emergency preparedness and response.

® Chapter 15 summarizes the successes in global health to date and examines priority areas for global health in the 21st century.

A transition guide showing how the first and second editions of Introduction to Global Health relate is available from the publisher,

Kathryn H. Jacobsen is an associate professor of epidemiology at George Mason University. She earned an MPH in International Health and a PhD in Epidemiology from the University of Michigan. Her research portfolio includes analyses of the global burden of disease and field projects in Africa, Asia, and the Americas. Dr. Jacobsen's work has been published by the World Health Organization and in dozens of international peer- reviewed journals. She is also the author of Introduction to Health Research Methods: A Practical Guide, published by Jones & Bartlett Learning.

xix

One hundred years ago, most populations around the world had similar disease profiles, with a high burden from infectious diseases. Modem medical technologies like antibiotics and vaccines have enabled many people to live longer, healthier lives. But modem lifestyles put a large number of people at risk for serious chronic diseases, and the disparities in health between the rich and the p()or have increased. Global health draws on a wide variety of disciplines in order to understand and improve the health of people around the world.

H?ti:AL'I'H

Health is often defined as the absence of disease (or the absence of illness, injury, infection, pain, tumors, or other physical disorders), but this is an incomplete explanation because it focuses on what health is not rather than on what health is. Some definitions of health try to capture its essence by emphasizing health as the ability to conduct normal daily activities. But that kind of statement is also limited, because the definition of "normal" varies from person to person. For example, some people assume that it is normal for an older person to have limited mobility and forgetfulness, but this is not true. Many older people are very active and mentally sharp, and many of those who have joint pain or memory loss could be helped by therapy and medication. Similarly, in many parts of the world parents think it is normal for their children to have intestinal worms. This is also not true, and untreated worm infections significantly reduce the health, growth, and school performance of millions of children around the world.

A more comprehensive definition of health addresses both physical and mental health as well as the presence of a social system that facilitates health. The Constitution ofthe World Health Organization (WHO), written

2 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

in 1948, defines health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." This defini- tion recognizes that health is not just a function of biology. Health stems from biology, psychology, sociology, and a host of other factors.

Although there is almost no one in the world today who would be clas- sified as having "complete" health according to the WHO statement, l this definition provides a target for medical and public health systems to aim for as they work together to promote the improved health status of individuals and communities.

1.2 MEDICINE AND PUBLIC HEALTH

Medicine is concerned with the health of individuals, and clinical health practitioners like physicians, surgeons, dentists, nurses, and physi- cal therapists are instrumental in helping individuals and families reach and maintain health by providing preventive, diagnostic, and therapeutic health services.

But because individual health is often the result of socioeconOInic, envi- ronmental, and other factors, medicine by itself is a limited approach to health. Clinicians, other health workers, social workers and counselors, spiritual advisors, government officials, trash collectors, farmers, and many other people in many other professions all make important contributions to the social, economic, policy, and physical environments that promote or inhibit the health of communities and nations and, by extension, the health of individuals and families.

Public health focuses on the health of populations, whether small villages or entire world regions. The public health system, which addresses health at local, state and provincial, national, and international levels, also works to keep individuals safe and healthy. The goals of public health include pre- venting illnesses, injuries, and deaths at the population level, identifying and mitigating environmental hazards, promoting healthy behaviors, ensuring access to essential health services, and providing health education targeted toward at-risk groups of people (Table 1_1).2 Both public health and medi- cine make important contributions to global health, but public health plays an especially important role because of its population focus (Figure 1-1). (The line between medicine and public health is also fairly blurry, with community health nurses and preventive medicine physicians working in both domains.)

1.2 Medicine and Public Health 3

Table 'i~'\ Essential public 11ealth services.

1 Monitor health status to identify community health problems.

2 Diagnose and investigate health problems and health hazards in the community.

3 Inform, educate, and empower people about health issues.

4 Mobilize community partnerships to identify and solve health problems.

5 Develop policies and plans that support individual and community health efforts.

6 Enforce laws and regulations that protect health and ensure safety.

7 Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.

8 Ensure a competent public health and personal healthcare workforce.

9 Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

10 Research for new insights and innovative solutions to health problems.

Source: Reproduced from the Centers for Disease Control and Prevention (2010). National Public Health Performance Standards Program (NPHPSP): 10 Essential Public Health Services. http://www.cdcogov/nphpsp/essentialservices .html. Last updated December 9,2010. Accessed August 31,2012.

Domain of Public Health

Domain of Medicine

1~1 The domains of medicine and public health.

4 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

1.3 THE EMERGENCE OF GLOBAL HEALTH

Global health refers to transnational health, health concerns that cross national borders. The term global health is sometimes used interchangeably with international health, but international health is now more often used to describe a focus on the health issues of people who live in lower-income countries. 3,4

Global health is not new. Infectious diseases have long been spread by migration and trade. By the mid-1800s, European countries had cooperation agreements in place to help control the spread of cholera, plague, yellow fever, and other epidemic diseases, and by the early 1900s international regulations addressed drugs and alcohol sales, occupational health and safety, and water pollution.s

In recent decades, global health as a field of work and study has expanded in scope and recognition as modernization and globalization have occurred. Modern transportation allows infectious diseases to spread across the world at an alarming rate. Advances in medical technology and pharmaceuticals are curing diseases that used to be untreatable, but new technologies have also created superbugs that are resistant to current antibiotic therapies. And the threat of bioterrorism requires coordination of public health responses from many nations. The increasing attention on global health also arises from the continued and growing disparities in health status between nations and within nations, which raise human rights concerns and may contribute to insecurity.

Although the main health concerns of communities in rural Africa (often HIV/AIDS and malaria) are very different from the key health concerns of urban Americans (often heart disease and cancer), there are important commonalities across the globe. Emerging infections such as multidrug- resistant tuberculosis (MDR-TB), rising cancer rates, and the high preva- lence of mental health disorders are concerns for everyone. Global health helps communities, nations, and the world prepare to respond appropriately to emergent health concerns.

1.4 HEALTH TRANSITIONS IN THE 20TH CENTURY

One hundred years ago, most populations across the world had similar health profiles: high birth rates, high death rates, short life expectancies, and a lot of disease and death due to infections and undernutrition. During the 20th century, most high-income nations made a transition to a lower

1.4 Health Transitions in the 20th Century 5

birth rate, a lower death rate, longer life expectancies, and a higher burden from the chronic diseases often associated with overnutrition. Low-income countries have not experienced such dramatic changes, but the health profiles of middle-income areas are currently shifting. These demographic, epidemiologic, and nutrition transitions are summarized in Table 1-2.

In the United States, the leading causes of death in 1800 and 1900 were pneumonia (including pneumonia caused by influenza), tuber- culosis, and diarrhea-all infectious diseases. 6 By 1950 the death rate had dropped significantly, life expectancy had increased, and the most common causes of death had shifted to heart disease, cancer, and stroke, the same noncommunicable diseases that are the most frequent causes of death today.7 These changes in population health status were due to a variety of factors, including new health technologies (such as new

Table 1-2 Health transitions.

Low-Income Areas (and most of the world Middle-Income

Category 100 years ago) Areas High-Income Areas

Demographic High fertility rate Intermediate Low fertility rate Transition fertility rate

Relatively high child Low child Very low child mortality rate mortality rate mortality rate

Relatively high Intermediate Relatively low mortality rate mortality rate mortality rate

Relatively low life Intermediate life Relatively high life expectancy expectancy expectancy

Children are a large Intermediate Older adults are a proportion of the aging profile sizeable proportion population of the population

Epidemiologic High burden from Dual burden of High burden from Transition diseases of poverty infectious and diseases of affluence

(infectious diseases) chronic diseases (chronic diseases)

Nutrition Underweight is a major Concerns about Overweight and Transition concern underweight in obesity are major

some popula- concerns tions and obesity in others

6 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

vaccines, new antibiotics, and new contraceptives), improved nutrition, increased education, and economic growth. 8

1.4.A Demographic Transitions

The demographic transition describes a shift toward lower birth and death rates that often occurs as populations move from being low-income economies (often referred to as developing countries) to being high-income economies (often called developed countries) (Figure 1_2).9 Pre-transition populations have high birth rates and high death rates, and the population maintains a stable, but relatively small, number of people. During the early stages of the demographic transition, increased food security and improved health care reduce the death rate, but the birth rate stays high and the population size increases, possibly drastically. In later stages, education, technology, economic growth, and other factors reduce the birth rates-a process called the

Birth rate

Death rate

Total population

Pre-transition: Early transition: Late transition: Post-transition:

High fertility rate Death rates begin Birth rates Low fertility rate and high death to decrease; the decrease; the and low death rate; stable population size population size rate; population population size increases increases size stabilizes

Figure 1-2 The demographic transition.

1.4 Health Transitions in the 20th Century 7

fe~"mjty tnmsiHon-and the population begins to stabilize at its larger size. Eventually, prolonged low birth rates may lead to a slow decline in population size.

The a shift from infectious diseases to chronic, noncommunicable diseases (NCDs) being the primary health problem in a population, often follows the demographic transition as the economic status of a population improves (Figure 1~3).10 The epidemiologic transitions that occurred in many high-income countries in the past century are now being seen in many middle-income areas. l1

During the years of transition, many of these countries are experiencing a burden of disease, as some population groups continue to suffer from diseases of poverty (such as infections, undernutrition, and compli- cations of childbirth), while other population groups bear a considerable burden from diseases of affluence (NCDs).

The complex epidemiologic profile of middle-income countries high- lights two key points. One is that socioeconomic conditions have a huge

Low Income

Lower Middle Income

Upper Middle Income

High Income

13 Noncommunicable disease deaths

D Injury deaths

!lSI Infection, undernutrition, and childbirth deaths

1-3 Proportion of deaths from various causes by country income level in 2008.

Source: Data from The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011.

8 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

influence on the diseases experienced by individuals and populations. There is heterogeneity in the disease profile within every country, with urban professionals in every part of the world having a very different health profile than the urban poor and rural residents surviving by subsis- tence farming. The other key observation is that every population at every income level has health concerns. Reducing deaths from infections and childbirth is an excellent public health achievement, especially because these conditions tend to kill young people. But those averted deaths will be replaced with other causes of death, often deaths from heart disease and cancer.

Thus, the goal of public health is not to prevent death, because everyone will eventually die of something. The goal of public health is to prevent premature death, and to promote long and healthy lives. By this standard, shifting the burden of disease from children and young adults to older adults is a good outcome, and that is what happens during the epidemiologic tran- sition. The burden of disease in pre-transition populations falls heavily on the young, while the burden of disease in post-transition popUlations falls mostly on the elderly. This can be seen in the age distributions of deaths in low- and high-income countries. In some low-income countries, more than one-third of the deaths that occur are of children; in high-income countries, nearly all deaths occur in older adults (Figure 1-4).12

100%

80%

60%

40%

20%

0% Low

Income Lower Middle Income

Upper Middle Income

High Income

1!2180+ III 70 to 79 III 60 to 69 .45 to 59 o 30 to 44 III 15 to 29 .5 to 14 .Oto4

Figure 1-4 Proportion of deaths by age group and country income level in 2008.

Source: Data from The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011.

1.4 Health Transitions in the 20th Century 9

It is also important to note that while the epidemiologic transition is a helpful model for understanding the differences in health status between higher- and lower-income countries and regions, the health changes that occur with economic development are much less predictable than the model implies. 13 Although many illnesses and deaths in low-income nations are due to infection and undernutrition and most illnesses and deaths in high- income nations are due to NCDs, globalization is reintroducing infectious diseases into industrialized nations and introducing new chronic diseases into developing nations. Every country in the world experiences a mix of deaths from infection, noncommunicable conditions, injuries, and other causes, even though the relative proportion of these causes of deaths differs by the country's income level.

The describes a population shift from a stage in which undernutrition and nutrient deficiencies are prevalent to an interme- diate stage in which undernutrition and obesity are both problems in the population to a stage in which overweight and obesity are the dominant nutritional disorders. 14 Pre-transition populations are concerned about hav- ing too little food and may consume primarily energy-dense foods that have a lot of calories but are low in nutrients. Children are at high risk of vitamin and mineral deficiencies because starchy staple foods fonn the bulk of the diet, and many children have stunted growth because they eat too few calories or too little protein. Few convenience foods are available, and a lot of effort goes into acquiring and preparing foods for consumption. Post- transition populations consume a greater variety of nutritious foods, but also eat more refined and processed foods, foods of animal origin, and fats. Most of these popUlations have shifted toward an industrialized economy that demands less physical labor from its workers, which exacerbates rising rates of obesity.

The nutrition transition provides a helpful framework for understand- ing the changing nutritional status of populations around the world, but an important new trend has emerged with the globalization of the food supply and with increasing urbanization in low-income countries: dis,ea;ses related to obesity and physical inactivity are now found among some populations even in pre-transition countries where the majority of families are food insecure and famine is a potential threat. 15

10 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

1.5 RISK FACTORS

A first step toward improving population health is identifying major health problems and conducting research to identify the characteristics of the people most likely to be affected by those conditions. After data about a population have been collected, statistics are used to see if an exposure or characteristic is associated with an increased likelihood of having a particular disease. If a statistically significant association is present, then the next step is to try to determine whether the exposure causes the disease. A causal factor is an exposure that has been scien- tifically tested and shown to occur before the disease outcome and to contribute directly to its occurrence. Identifying causation requires more than just statistics. It also requires logical thinking (Table 1_3).16,17 For example, there may be a statistical association between hot weather and the number of shark attacks, but that does not prove that hot weather causes sharks to fall into a frenzy. A more likely explanation is that hot weather increases the number of humans in the water, which increases the number of humans attacked. For that matter, there may be an associa- tion between ice cream sales and shark attacks. Removing the "risky" exposure by banning ice cream sales at the beach would probably not do much to prevent shark attacks, unless people stopped going to beaches because of the absence of ice cream.

A risk factor is an exposure or characteristic that increases the like- lihood of developing a particular disease. Age, ethnicity, and genetic markers for certain diseases are examples of unmodifiable risk factors that cannot be changed. Behavioral risk factors, such as tobacco smok- ing and exercise habits, and other modifiable risk factors can be altered, even if making lifestyle changes is challenging for the individuals and the communities who are trying to adopt healthier behaviors. The goal of public health is not merely to identify problems, but to use that infor- mation to promote health and prevent disease. Once a major risk factor for a disease has been found, policy or programmatic interventions to reduce exposure to the risk factor (or to promote a protective factor) can be designed and implemented.

Some diseases have no currently known modifiable risk factors. It is not always possible to identify the etiology, or cause, of a particular disease or the risk factors for it, at least not with current technology. For example, the etiology of many neurological conditions like Parkinson's disease and epilepsy are unknown in most cases, as are the causes of many mental ill- nesses, autoimmune diseases, and other conditions. For these disorders, the

1.5 Risk Factors 11

Table cl~3 Criteria for causation.

Criterion

Is the association strong?

Is there clear temporal- ity (time sequence)?

Is there a dose- response eHect?

If an experiment removes the risk factor does that reduce the risk of the disease?

Other criteria

Explanations/Examples

If smokers are 15 times more likely to develop lung cancer than nonsmokers, that is stronger evidence of causality than if smokers are 1.1 times more likely to develop lung cancer. Prevalence of the disease (the total amount of disease in a population) should be significantly higher in those exposed to the risk factor than those not. In studies that follow people over time (longitudinal studies), the incidence of the disease (number of new cases in a population) should be significantly higher in those exposed to the risk factor than those not exposed.

Exposure to the agent or risk factor must precede development of the disease, and the disease should follow exposure to the risk factor within a predictable time frame.

If exercising for 3 hours a week is slightly protective against breast cancer and exercising for 6 hours a week is more protective, it is more likely that exercise is protective than if the extra hours of exercise are not associated with increased protection. If exposure to radiation is harmful, then people with higher radiation exposure should be sicker than people with minimal exposure.

People who are exposed to the risk factor should develop the disease more frequently than those who do not have the exposure, and exposure to the risk factor should be more frequent among those with the disease than those without. Reducing or eliminating the risk factor should reduce the risk of the disease.

Is the link between the exposure and the outcome specific, biologically plausible, and consistent with existing knowledge? Have alternate explanations for the apparent causation been considered? Have dil'ferent studies in different populations made consistent conclusions?

Source: Causal criteria from Hill AB. The environment and disease: asso- ciation or causation? Proc R Soc Med. 1965;58:295-300; and Evans AS. Causation and disease: the Henle-Koch postulates revisited. Yale J Bioi Med. 1976;49:-175-195.

12 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

public health focus is on research to identify causal factors and on support for the individuals andfamilies affected by the conditions.

But most diseases do have known risk factors and known protective factors. Many diseases are multifactorial, which means that they have many different causes and multiple risk factors. A risk factor is said to be a necessary part of the disease pathway if it must be present for a person to develop a disease. A risk factor is sufficient if that exposure or charac- teristic by itself can cause disease. Some exposures are necessary but not sufficient on their own to cause disease. Some exposures are sufficient but not necessary. Few risk factors are both necessary and sufficient. However, when several risk factors are present together they can create a situation in which disease can develop.

For example, heart disease is caused by the build-up of plaque on the walls ofthe arteries that supply blood to the heart. This build-up is associ- ated with high cholesterol levels in the blood, inflammation, infection, and genetics. Diet, stress, and physical inactivity also contribute to the develop- ment of cardiovascular disease. Thus, there are many risk factors for heart disease and many targets for prevention. A broken hip may directly result from a fall, but the underlying cause of the fracture might be osteoporosis (loss of bone density) caused by genetics, inactivity, lack of calcium in the diet during childhood, endocrine disorders, or one of many other medical conditions, and the fall itself may have occurred because of a loss of bal- ance due to a nervous system disorder like Parkinson's disease or multiple sclerosis, or because of vision problems, or because of not living in a barrier-free home or with someone who can assist with tasks that require reaching or balancing. Addressing anyone of these contributing factors may prevent a negative health outcome.

Public health considers personal biology, psychology, behavior, and other characteristics to be only a starting point for understanding the risk factors for disease. A person's friends, family, and coworkers also contrib- ute to the health problems that an individual is likely to encounter, whether that is an increased risk of knee injuries in a person whose closest friends are avid basketball players or an increased risk of obesity in a person whose family gatherings are built around high-calorie foods. Living and working conditions, such as the quality of housing available in a person's neighbor- hood and whether local employers provide health insurance, add another layer of factors that affect health. And broader social, cultural, economic, political, environmental, and policy considerations also influence individual and community health.18 Targeting a risk factor at anyone of these levels can improve personal and public health (Figure 1-5).

1.6 Prevention 13

$QQia'lfj€!ni\i<Qtl~s:'1 Living and working conditions

(including access to health services)

Broader social, cultural, economic, political, environmental, and

policy conditions

1-5 Contributors to individual and population health.

Source: Adapted from the Committee on Assuring the Health of the Public in the 21st Century. Thefuture afthe public's health in the 21st century. Washington DC: National Academies Press; 2002.

A c;;wsal web can be used to display the relationships among the many different biological, behavioral, social, economic, political, and environ- mental exposures that might have a causal relationship with a particular health outcome. Causal webs indicate the immediate causes of disease and also show more distant causes. For example, 1-6 shows the

.. Refrigeration for safe food

causing agent

1~·6 Sample causal web for infectious diarrhea.

14 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

relationships between both direct and less direct causes of infectious diar- rhea, which is usually acquired through the ingestion of fecally contami- nated food or water.

When a complex set of characteristics contribute to causing disease, there are also multiple paths to a solution. Interrupting any of the path- ways shown on a causal diagram may prevent the disease outcome for at least some members of a population. An intervention that removes anyone of the arrows in Figure 1-6, whether by introducing electricity to a rural community to allow for refrigeration, teaching illiterate moth- ers to read, or bringing low-cost water filters to an urban slum, could be successful in preventing at least some cases of childhood diarrhea. Solutions to community and global health concerns often must address broad socioeconomic and environmental issues and not just household problems.

There are three levels of prevention (Table 1-4). When modifiable risk factors for a disease have been identified, the goal is primary prevention, preventing the disease from ever occurring. Primary prevention methods include immunizations, improved nutrition, adequate sleep, safety devices, health education, and any interventions that reduce susceptibility to infec- tion, injury, or disease. The goal of secondary prevention is to diagnose disease at an early stage when it has not yet caused significant damage to the body and can be treated more easily. The aim of tertiary prevention is to reduce complications in those with symptomatic disease in order to prevent death or minimize disability.

Given the three levels of prevention, there is almost always some inter- vention that could improve the health of those who are vulnerable to a particular disease or are already sick. Most public health campaigns focus on primary prevention, such as the promotion of hand washing, breastfeed- ing, mosquito net use, family planning methods, and immunizations. Some prevention work focuses on changing the health environment by spraying insecticides to kill the mosquitoes that spread infections, implementing clean delivery room practices to prevent infections of new mothers and newborns, and increasing access to improved sanitation facilities to pre- vent diarrhea. Other efforts focus on improving access to health care and health insurance, to essential medications and micronutrient supplements, and to healthy foods through community-building and policy changes. These are in addition to secondary prevention activities such as screening promotions and tertiary prevention methods that treat existing diseases and disabilities.

]] Careers in Global Health 15

Table 1-4, Levels of prevention,

Level

Primary Prevention

Secondary Prevention

Tertiary Prevention

Also Called ...

Target Population Goal Examples

Prevention People without disease

Prevent " Giving vitamin A cap- disease from sules to at-risk children ever occurring to prevent blindness

Early diagnosis

People with early, non- symptomatic disease

Reduce the severity of disease and prevent disability and death

Treatment People with Reduce and reha- symptomatic impairment bilitation disease and minimize

suffering

@ Giving tetanus shots to pregnant women to prevent tetanus

" Screening with mam- mography to detect cases of breast cancer in early stages

" Checking blood pressure routinely to detect early hypertension

.. Detecting cases of acute respiratory infections in children early so they can be treated with antibiotics

" Checking for foot problems among dia- betic persons so they do not develop into severe ulcers

" Providing physical therapy to people who have been injured in a vehicle accident in order to prevent long-term disability

Global health professionals work in a variety of fields to promote population health. Among other roles, global health workers track outbreaks of infectious diseases, develop new vaccines, monitor the safety of medications, assess environmental risk factors for disease, educate communities about diabetes

16 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

care, and promote HIV / AIDS awareness and prevention. Public health geneti- cists determine which genes are associated with an increased risk of cancer. Public health educators and nutritionists work with schools and communities to reduce risky behaviors, such as unsafe sex, drug use, and reckless driving, and to promote healthy behaviors such as wearing bicycle helmets, getting screened for cervical cancer, and eating vegetables. Environmental public health experts develop plans for communities that want to reduce the spread of infections caused by insect bites. Public health administrators work with hospitals and physicians, elected officials and lawyers, biomedical researchers, the pharmaceutical industry, and others to promote health.

People who want to work in global health need to understand the social and environmental contributors to disease and the biological causes of dis- ease. They must be familiar with the traditional areas of international health, such as infectious disease, nutrition, child health, reproductive health, and water and sanitation. They must also be knowledgeable about emerging global public health concerns, such as aging, mental health, injury preven- tion, and food safety. An understanding of the impact of poverty, culture, and economic globalization on health is also essential.

The diversity. of work within global health means that there are many pathways to getting started in a global health career. Many professionals working in the field have training in at least one of the core disciplines of public health, which include health education and health behavior; epide- miology and biostatistics (the fields that focus on measuring health status in populations); environmental health; and health policy, health economics, and health administration and management. Global health professionals may also· specialize in areas such as public health nutrition, maternal and child health, emergency preparedness and response, and public health research. Common undergraduate majors for those preparing for global health careers include biology, psychology, sociology, and the health sci- ences, and majors in fields like business, communications, economics, political science, international relations, and statistics can also offer excel- lent preparation. Every area of study provides tools that can be applied to improving public health as a professional or as a volunteer.

1.8 DISCUSSION QUESTIONS

1. How has the medical system contributed to your health? Based on the list of public health services in Table 1-1, how has the public health system contributed to your health? What are the differences in how medicine and public health influence your health?

References 17

2. What are some of the most significant health concerns in your com- munity? Are these concerns that are likely to be shared by other com- munities in your country and in other parts of the world? Could these problems be considered global health issues?

3. Do you agree that shifting the burden of disease and death from the young to the old is a successful public health outcome?

4. Choose one relatively common disease affecting health in your com- munity, then list as many risk factors for that disease as you can think of in 2 minutes. How many ofthe risk factors on your list are modifiable? How many are necessary? How many are sufficient? What interventions would reduce the number of people in your community who develop the disease?

5. Sketch out a causal web for a relatively common disease in your country, adding at least 10 risk factors to the figure. Based on the arrows on your web, what interventions might prevent the disease from occurring?

6. What are some examples of primary prevention, secondary preven- tion, and tertiary prevention activities you have engaged in during the past year?

7. How does global health relate to your major field of study and/or the field you are working in?

1. Huber M, Knottnerus JA, Green L, et al. How should we define health? BMJ. 2011;343:d4163.

2. Harrell JA, Baker EL; Essential Services Work Group. The essential services of public health. Leadersh Public Health. 1994;3:27-30.

3. Koplan JP, Bond TC, Merson MH, et al.; Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373: 1993-1995.

4. Brown TM, Cueto M, Fee E. The World Health Organization and the transition from "international" to "global" public health. Am J Public Health. 2006;96:62-72.

5. Fidler DP. The globalization of public health: the first 100 years of international health diplomacy. Bull World Health Organ. 2001;79:842-849.

6. Jones DS, Podolsky SH, Greene JA. The burden of disease and the changing task of medicine. New Engl J Med. 2012;366:2333-2338.

7. Guyer B, Freedman MA, Strobino DM, Sondik EJ. Annual summary of vital sta- tistics: trends in the health of Americans during the 20th century. Pediatrics. 2000;106:1307-1317.

8. Martens P. Health transitions in a globalising world: towards more disease or sustained health? Futures. 2002:34:635-648.

9. Kirk D. Demographic transition theory. Pop Studies. 1996;50:361-387.

18 CHAPTER 1 GLOBAL HEALTH AND HEALTH TRANSITIONS

10. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Mem Fund Q. 1971;29:509-538.

11. The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011. 12. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global burden of disease

and riskfactors. Washington DC: Oxford University Press and IBRDlWorld Bank; 2006. 13. Caldwell Je. Population health in transition. Bull World Health Organ. 2001 ;79: 159-170. 14. Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet linked

with noncommunicable diseases. Am J Clin Nutr. 2006;84:289-298. 15. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev. 2007 ;29: 1-5. 16. Hill AB. The environment and disease: association or causation? Proc R Soc Med.

1965;58:295-300. 17. Evans AS. Causation and disease: the Henle-Koch postulates revisited. Yale J Bioi Med.

1976;49: 175-195. 18. Committee on Assuring the Health of the Public in the 21st Century. Thefuture of the

public's health in the 21st century. Washington DC: National Academies Press; 2002.

2,1 THE OF HEALTH

As more resources are being devoted to global health efforts, it is becoming increasingly important to quantify the health needs in various parts of the world, to identify major modifiable risk factors for common diseases, to assess the impact of new public health interventions, and to monitor changes in the health status of populations over time. All of these measures provide an evidence base for making policy and funding decisions. 1 This chapter describes the key measures of health and disease used in global health, the major categories of disease, and several helpful sources of reliable health information.

In order to highlight key measures of global health throughout the book, eight countries representing a range of world regions and economic statuses will be highlighted in most chapters 2',._1)?-4 These countries also represent a range of population sizes, including the three most populous countries in the world (China, India, and the United States), but also Sierra Leone, which is not among the 100 most populous countries. Statistics for nearly all of the other countries in the world are available from the same sources provided for each data table and graph in the book.

Table 2-1 Basic information for featured countries in 2011.

Country USA South Korea Poland Brazil China India Kenya Sierra Leone

World North East Asia Europe South East Asia South Asia East Africa West Africa region America America

Income group High High High Upper Upper Lower Low Low Middle Middle Middle

Income group 5 years High High Upper Lower Lower Low Low Low before (in 2006) Middle Middle Middle

Human development 4 15 39 84 101 134 143 180 ranking (out of 187 ranked countries)

Population size 313 million 48 million 38 million 197 million 1348 million 1242 million 42 million 6 million

Source: Data from Human development report 2012. New York: UNDP; 2012; and World development report 2011. Washington DC: World Bank; 2011; and World development report 2006. Washington DC: World Bank; 2005.

N o

n ~

~ ~ N

~ t!1 > en C ~

52 C"l ..., ~ t!1

o t-< o t:C > t-< to C ~ ti t!1 Z o '1"j

t:I ..... en t!1 > en t!1

2.2 Measuring Health and Disease 21

2.2 MEASURING HEALTH AND DISEASE

The key measures of health and disease in a population include information about population size, the birth rate and death rate, the causes of death, the frequency and causes of disease and disability, and the rate at which members of the population engage in risky behaviors.

is the study of the size and composition of human populations. Most countries maintain v:ital statistics on their residents, which are collected from birth and death certificates, from marriage and divorce certificates, and from census records. Demographers use these statistics to understand the current population distribution and to predict the size and characteristics of the population in future years.

The birth rate is the annual number of births per 1000 people in the total population and the death rate (or is the annual number of deaths per 1000 total population. The death rate is usually higher in popula- tions with a large percentage of older adults than in populations with lots of children, so an rate that accounts for differences in the age structures of populations is usually used to compare mortality rates in two or more populations.

Identifying when an individual has died is fairly uncomplicated, but measuring at the population level can be challenging for two principal reasons. The first is that in many parts of the world there is no system for reliably registering vital statistics. In places where most births and deaths occur in homes instead of in hospitals, few births and deaths are documented by government officials. The most disadvantaged populations-often the ones with the highest mortality rates-are the least likely to have their life events accurately counted. Thus, while very precise mortality statistics are available from high-income countries, death rates in low-income countries often have to be estimated based on limited data. The second key challenge is assigning one cause of death to each deceased individual. Should a person with HIV/AIDS who dies of tuberculosis be recorded as an AIDS death or a TB death? Should a person

22 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

with advanced-stage cancer who dies of pneumonia be counted as a cancer death or an infectious disease death? These decisions about how to assign causes of death can have a significant impact on which diseases appear to be the most common causes of mortality in a population. Even with these limitations, epidemiologists using standardized estimation methods and the best available data are able to make reasonably accurate assessments of the annual number and causes of death by age group and sex in every region of the world.

Another common way of examining mortality and survival at the popula- tion level is through the estimation of life expectancy. Life expectancy at birth is the median expected age at death of all babies born alive. Some estimates of life expectancy instead focus on healthy life expectancy, which is the number of years the average individual born into the population can expect to live without disability (Figure 2-1).5 Life expectancy captures the

USA South Poland Brazil China India Kenya Sierra Korea Leone

Figure 2-1 Life expectancy at birth (in years) and healthy life expectancy at birth in 2000. The total height of each bar represents total life expectancy at birth. The lighter portion of the bar represents the number of years the average person in the region is expected to live a healthy life, and the darker portion of the bar represents years the average person is expected to live with disability.

Source: Data from Mathers CD, Murray CJL, Lopez AD, et al. Estimates of healthy life expectancy countries for 191 countries in the year 2000: methods and results. WHO Global Programme on Evidence for Health Policy Working Paper No. 38. Geneva: World Health Organization; 200l.

2.2 Measuring Health and Disease 23

burden from infant and child deaths in addition to the average age at death of adults. In places with high infant mortality rates, the median age at death is often in middle adulthood, which represents an age somewhere between a large number of child deaths and an even larger number of deaths in older adults.

While there are considerable differences life expectancy at birth between various countries and world regions, the life expectancy of people who have already survived to adulthood is relatively similar across nations

6 In most parts of the world an adult who has survived to age 50 can expect to live into his or her 70s or beyond and a person who has survived to age 70 can expect to live until about age 80. This is one of the reasons why aging is a concern in all countries, even those with a relatively low life expectancy at birth.

Table 2~2 Life expectancy by age in 2009.

South Sierra Country USA Korea Poland Brazil China India Kenya Leone

At least half of 76 77 72 70 72 63 58 48 newborns will live until age ...

At least half 77 77 72 72 73 67 63 60 of 5-year-old children will live to age ...

At least half of 80 79 75 76 76 73 72 70 50-year-old adults will live to age ...

At least half of 84 83 82 83 81 80 80 79 70-year-old adults will live to age ...

At least half of 91 90 90 91 90 89 89 89 85-yeaNJld adults will live to age ...

Source: Data from World health statistics 2011. Geneva: WHO; 2011.

24 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

2.2.C Measuring Morbidity

Morbidity refers to the presence of illness or disease, whether that disease is relatively mild, like the common cold, or quite severe. The two most common terms used to describe the morbidity rate for a particular dis- ease in a population are incidence and prevalence. Incidence is the number of new cases of the disease occurring in a time period divided by the total number of people at risk for that disease in that time period. Incidence is usually used to study infectious diseases, acute diseases (diseases that occur suddenly), and outbreaks. Prevalence is the number of total existing cases, both newly diagnosed cases and cases diagnosed in the past, divided by the total number of people in the population at the time the prevalence is measured. Prevalence is usually used to describe the amount of chronic (long-lasting) disease in population, such as the proportion of a population with diabetes, asthma, or schizophrenia. The difference between the two terms is illustrated in Figure 2-2.

One of the goals of public health is to decrease the incidence and prevalence of diseases and disabilities. For example, the incidence of a

December 31, 2011

0000000000 0000000000 0000000000 0000000000 0000000000 0000000000 0000000000 0000000000 •••••••••• ••••••••••

At the end of 2011, there were 100 adult residents of Villagetown and 20 of them had HIV infection.

The prevalence of HIV infection was 20/100 = 20%.

December 31, 2012

0000000000 0000000000 0000000000 0000000000 0000000000 0000000000 0000000000 @iH~.\\\UUUt.oo

•••••••••• • ••••••••• At the start of 2012, there were 80 susceptible adults in Villagetown. During 2005, 8 became newly infected with HIV.

The one-year incidence rate of HIV infection was 8/80 = 1/10. One in 10 susceptible adults became infected.

Assuming that all of the adults survived to the end of 2012, there were 100 adult residents of Villagetown and 28 of them had HIV infection.

The prevalence of HIV infection was 28/100 = 28%.

Figure 2-2 An example of incidence and prevalence.

2.2 Measuring Health and Disease 25

disease may decrease if a new vaccine or other preventive measure becomes available, and the prevalence of a disease usually decreases if a new therapy cures lots of cases of the disease. These successful interventions are said to increase the number of UJe years for recipients by adding to the duration and quality oflife. However, there are some times when an increased prevalence is considered to be a public health success. For example, the reported prevalence of a disease may increase when a new diagnostic test allows more people with the disease to be properly diag- nosed or when a new therapy allows people to live longer after developing the disease, even if the treatment does not cure the disease.

Health researchers measuring the l:m~['(len or disease in a population must have a clear case that spells out exactly what characteristics indicate that a person has the disease of interest. They must also specify a well-defined population of interest, especially if the researchers are tracking changes in the health status of a population over time. (Because the prevalence of disease in a community may change due to the migration of sick people into the community or the migration of healthy people out of the community, some studies track individuals rather than just whole towns or cities.) Age-adjustment can be used to standardize two populations with different age structures before their morbidity rates are compared.

2.2J)

The yeaR· is a way of estimating the burden of disease in a population by combining the burden from premature deaths, measured as years plus the burden from disability, measured as years Weights are assigned to the level of disability caused by each type of physical or mental health condition. Diseases that kill children, who would have had decades of productive life remaining had they survived, and chronic conditions that limit productivity for lengthy periods of time result in many YLLs and YLDs.

One of the key benefits of the DALY is that it highlights the high burden of disability caused by mental health disorders. Neuropsychiatric conditions (including conditions like Alzheimer's disease, epilepsy, and Parkinson's dis- ease as well as depression, anxiety disorders, schizophrenia, and other mental health issues) and self-inflicted injuries are estimated to account for 305% of deaths worldwide each year, but they contribute more than 14% of DALY s. 7

The main criticism of DAL Y s is the difficulty in assigning weights to the amount of disability caused by various illnesses and impairments. It will

26 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

never be possible to assign an accurate weight to the decrease in quality of life caused by blindness, loss of a limb, depression, a brain tumor, or asthma, because the experience of disability varies so much based on the individual, living conditions, the level of community support, access to health care, and other individual factors. For example, the amount of disability caused by an amputated foot would be much higher for a manual laborer in a low- resource setting where prosthetics are not available than it would be for an office worker in a place where high-tech prosthetics are common.

2.2.E Quantifying Risk Factors

Health metrics also seek to identify risk factors for death, disease, and disability, and to measure the number of people worldwide who are exposed to these risks. The focus is usually on modifiable risk factors, because the prevalence of these exposures can be reduced with public health interven- tions. Some of the most common preventable risk factors are listed in Table 2-3. Different countries have different risk profiles, and in many places men and women have somewhat different sets of risks (Table 2-4).

Table 2-3 Common risk factors for morbidity and mortality.

Health-related Nutritional Environmental Untreated Medical Behaviors Exposures Exposures Conditions

• . Tobacco use • Overweight and • Indoor smoke • High blood

• Physical obesity from solid fuels pressure

inactivity • Child • Unsafe water, (hypertension)

• Unsafe sex underweight sanitation, • High blood

• Alcohol abuse • Low fruit and hygiene glucose (hyper-

vegetable intake • Urban outdoor glycemia, which • Lack of air pollution is a risk factor

contraception • High fat intake for diabetes) • Illicit drug use • Suboptimal

• Occupational • High cholesterol

breastfeeding risks (hypercholester-

• Vitamin A • Lead exposure olemia) deficiency

• Chronic cancer- • Zinc deficiency associated • Iron deficiency infections

Source: Information from Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011; and Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.

1'8bl'9 :2-4 Prevalence of selected risk factors in 2008.

Age Group South Sierra Country (years) Sex USA Korea Poland Brazil China India Kenya Leone

Male 33 49 36 22 51 26 26 39 Prevalence (%) of tobacco use 2:25

Female 25 7 25 13 2 4 1 8

Male 34 24 47 30 13 15 16 Physical inactivity (%) 2:15

Female 47 32 52 32 18 18 24

Alcohol consumption per person 2:15 Both 10 15 14 10 6 3 4 10

per year (liters)

Prevalence (%) of high blood Male 17 18 41 39 30 23 37 42 2:25

pressure (? 140/90 mm Hg) Female 14 13 33 27 26 23 33 41 N Male 123 124 135 133 128 124 132 135 tv

Mean blood pressure (mm Hg)* 2:25 Female 118 117 130 125 124 123 130 135 ~

Prevalence (%) of high fasting Male 13 7 8 10 11 11 8 9 '" ;;:: 2:25 ..., blood glucose* Female 9 5 7 10 10 11 8 10 S·

00 Male 30 7 23 17 5 1 3 4

~ Prevalence (%) of obesity 2:20 Female 33 8 23 22 7 3 7 10 ~ -..

'"" Mean blood cholesterol level Male 5.1 4.8 5.3 4.8 4.5 4.3 4.3 3.8

2:25 ~ (mmoIlL)* Female 5.2 4.9 5.2 4.9 4.6 4.5 4.4 4.1 ;:s ~

t:J *These values are age-standardized so that the countries' values can be compared. SBP 2: 140 mm Hg is considered to be C:;.

('0

hypertension and cholesterol 2: 5.0 mmol/L is considered to be hypercholesterolemia. Medication can be used to lower both of ~ '" these values. ('0

Source: Data from Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group. Country trends in metabolic risk factors. London: Imperial College London; 2011; and Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U; N Lancet Physical Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls, and prospects.

--.l

Lancet. 2012;380:247-257; and World health statistics 2012. Geneva: WHO; 2012.

28 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

r:2l Tobacco use

Q Physical inactivity

Iil Alcohol abuse

Ii!ill Low fruit and vegetable intake

Ii Hypertension

Q Overweight and obesity

Ii High cholesterol

III Cancer-associated infections

D (Other causes)

2~3 The proportion of noncommunicable disease deaths worldwide in 2008 attributable to various risk factors.

Source: Data from Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

A few of these preventable risk factors are responsible for a sizeable proportion of all global deaths each year. For example, more than 10% of adult deaths worldwide are attributable to tobacco use, 8 alcohol consump- tion is the cause of about 4% of deaths worldwide every year,9 and vitamin and mineral deficiencies contribute to more than 10% of the annual deaths of young children. lO Together, modifiable risk factors are thought to be responsible for at least two-thirds of all worldwide deaths from noncom- municable diseases like heart disease, stroke, diabetes, cancer, and chronic lung diseasell Other exposures increase the risk of morbidity or mortality from particular diseases,12-14 For example, outdoor air pollution may be the cause of 5% of lung cancer deaths worldwide, IS more than half of all strokes are attributed to high blood pressure,16 and more than 70% of cases of cervical cancer are associated with chronic infection with human papillomavirus (HPV).17 Identifying common contributors to reduced indi- vidual and population health allows health scientists, clinicians, educators, and individuals to prioritize actions that lessen exposure to these hazards. 18

In addition to measuring health outcomes like mortality and disability, it is important to track the performance of health systems, the financers and providers of health care arId public health services, because the health of a

2.3 Classifying Disease 29

population is often a function of the access of its members to essential health services. Health systems metrics may involve quantifying the coverage rates for various interventions, tallying the financial, human, and material resources put into health systems, evaluating the satisfaction of clients with health service providers and public health programs, determining which interventions are cost-effective, and tracking the inequalities that may remain within a health system. 1 This information provides a foundation for priority setting and for evidence-based policy and practice.

The World Health Organization and most of the Global Burden of Disease studies use three main classifications for causes of death and disability: (1) communicable (infectious) diseases (a category often grouped with pregnancy-related conditions, diseases of newborns, and nutritional deficiencies), (2) noncommunicable conditions (including mental health disorders), and (3) injuries. The proportion of deaths 2-4) and DALY s due to each of these categories varies significantly between countries in different income strata. 7

i!i Injuries

IilI Neuropsychiatric

D Noncommunicable diseases

[J Maternal and perinatal conditions and nutritional deficiencies

I!!lI Communicable diseases

2~4 Estimated proportion of deaths due to communicable diseases, noncommunicable diseases, and injuries in 2004.

Source: Data from The global burden of disease: 2004 update. Geneva: WHO; 2008.

30 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

II Injuries

Ii1 Neuropsychiatric

o Noncommunicable diseases

I'J Maternal and perinatal conditions and nutritional deficiencies

III Communicable diseases

2r5 Estimated proportion of DALY s due to communicable diseases, noncommunicable diseases, and injuries in 2004,

Source: Data from The global burden of disease: 2004 update, Geneva: WHO; 2008,

Communicable diseases are caused by infectious agents such as bacteria, viruses, fungi, and parasites (such as protozoa and helminths/worms). Tuberculosis, sexually transmitted infections, intestinal worms, meningitis, malaria, and respiratory infections are all in this category, In the early and middle part of the 20th century, the use of microscopes and the development of new laboratory techniques led to the identification of many microbes and the development of vaccines and antibiotics like penicillin. These discov- eries generated a great deal of optimism and confidence about the ability of humans to control and eradicate communicable diseases. However, although modem science has provided a good understanding of the infectious disease process and allowed for the development of therapies and cures for many types of infection, scientists now recognize that microbes continue to adapt and to emerge. Even with improved prevention and therapeutic techniques, infectious diseases continue to be a health risk in all populations in every of the world. Developing new vaccines, treatments, and prevention methods remains an important part of global health.

2.3 Classifying Disease 31

This disease category is often grouped with other conditions that primarily affect lower-income populations: perinatal conditions (diseases of newborns), maternal conditions, and nutritional deficiencies. Perinatal conditions include low birthweight, premature (early) birth, birth asphyxia, and birth trauma. Maternal conditions are those related to pregnancy, childbirth, and the hours after giving birth. Malnutrition may result when a person does not consume nutrients in the right quantities and combination. Taking in too few, or too many, calories or nutrients can be a cause of poor health. In addition to under- weight- and obesity-related conditions, malnutrition includes deficiencies of particular vitamins and minerals, such as iron, vitamin A, zinc, and iodine.

are condi- dons that are not contagious, such as heart disease and other cardiovascu- lar diseases, cancers, chronic respiratory diseases, endocrine and metabolic disorders, digestive diseases, kidney diseases, musculoskeletal and skin diseases, and neurological and psychiatric disorders Most noncommunicable conditions are chronic diseases that develop gradually and last for a long time.

Noncommunicable conditions result from a variety of etiologic pro- cesses. Some NCDs are caused by inflammation and by immune system dysfunctions. The immune system helps the body to fight disease by recognizing and attacking invaders like infectious agents and allergens. Autoimmune disorders like lupus and rheumatoid arthritis occur when the body has trouble distinguishing between "self' and "nonself' and begins to attack its own cells. Allergies are another type of immune dysfunction in which the body is hypersensitive to substances that are usually not harmful. And although the process is not yet well understood, inflam- mation appears to playa role not just in arthritis and other conditions in which swelling is easily observed, but also in heart disease and possibly in diabetes, cognitive disorders, and many other conditions. Poor nutrition and some infections (like HIV) can also cause immune system suppres- sion and lead to other illnesses.

Some noncommunicable conditions are caused by genetic disorders present at birth. Genes are sequences of nucleic acids that are pmi of the chromosomes that are found in the nucleus of every cell in the human body.

32 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

n!bil?! 2-5 Examples of noncommunicable conditions.

Cardiovascular .. Ischemic heart " Cerebrovascular " Rheumatic heart Diseases disease (heart disease disease

attacks) (strokes) .. Congestive heart .. Hypertension failure

Blood " Anemia .. Sickle cell " Hemochromatosis Disorders .. Hemophilia .. Thalassemia

Cancers OJ Lung cancer " Lymphoma .. Pancreatic cancer

" Stomach cancer .. Mouth and .. Bladder cancer

.. Colorectal throat cancer .. Ovarian cancer cancer " Prostate cancer ., Uterine cancer

.. Liver cancer " Leukemia .. Melanoma and " Breast cancer .. Cervical cancer other skin cancers

" Esophageal cancer

Respiratory .. Chronic obstruc- .. Asthma .. Cystic fibrosis Diseases tive pulmonary

disease (COPD)

Endocrine .. Diabetes .. Thyroid disease '" Adrenal dis- and Metabolic orders (like Disorders Addison's disease

and Cushing's syndrome)

Digestive " Cirrhosis of the ~ Hernias " Inflammatory Diseases liver .. Peptic ulcer bowel disease

.. Gallstones disease Ii Hemorrhoids

Genitourinary .. Kidney disease " Benign prostatic " Pelvic inflamma- Diseases hypertrophy tory disease (PID)

(BPH)

Musculoskeletal .. Muscular .. Osteoarthritis OJ Osteoporosis Diseases dystrophy .. Rheumatoid

arthritis

Skin Diseases .. Acne .. Eczema '" Psoriasis

Oral Diseases " Dental caries ., Periodontal " Edentulism (cavities) disease (toothlessness)

Sense Organ ., Blindness ., Cataracts .. Macular Disorders " Deafness .. Glaucoma degeneration

2.3 Classifying Disease 33

This genetic material directs every function of the body, including cell rep- lication, which is important for healing as well as for growth and develop- ment. Each cell contains identical DNA (deoxyribonucleic acid), although only some parts of the code are active in certain cells, which is why cells in a person's heart form different kinds of tissue than the cells that line the intestine. A is the version of a gene a person carries and a rtltAenl[)1[:-7'!Yeis the way a characteristic that results from having a particular

or version of a gene, is expressed-perhaps in physical appearance, the way a person develops or functions physiologically, or disease status. Some alleles are which means that inheriting a copy of that allele from either parent will cause a person to display the phenotype associated with that allele. For example, Huntington's disease, which causes a progres- sive degeneration of brain cells, is an autosomal dominant genetic disorder. Some alleles are which means that a person must inherit a copy of the allele from both parents to display the phenotype associated with the allele. Cystic fibrosis, sickle cell disease, and hemophilia are examples of autosomal recessive disorders. Some conditions are caused by the presence of an extra chromosome or a missing part of a chromosome. For example, Down syndrome (trisomy 21) is the result of an extra 21st chromosome. Other conditions are caused by genetic permanent changes in the sequence of bases that make up DNA that occur after birth. These mutations may result from exposure to radiation, chemicals, pollutants, or other substances. Cancers generally involve a series of mutations that lead to. tumor development.

The causes of many NCDs are not yet clear. However, all of the most common causes of NCD death-heart disease, cancer, stroke, chronic obstructive pulmonary disease (COPD), and diabetes-are linked to unhealthy behaviors such as tobacco use, physical inactivity, overconsump- tion of alcohol, and diets that are low in fruits and vegetables and high in fats. ll NCDs are the leading cause of death of adults in every part of the world

Di§OIrders

The neuropsychiatric conditions category includes mental illnesses as well as developmental disorders (such as mental retardation), autism spec- trum disorders, neurological disorders (such as Parkinson's disease, mul- tiple sclerosis, cerebral palsy, and migraines), seizure disorders such as epilepsy, and dementi as like Alzheimer's disease. There are a wide variety

34 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

800+-------------------------------------------

600 +------------

400

200

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 2-6 Age-standardized noncommunicable disease (NeD) mortality rate per 100,000 people in 2008.

Source: Data from Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

of recognized mental illnesses, including anxiety disorders, mood disorders, impulse-control disorders, substance abuse, and schizophrenia and other delusional disorders (Table 2-6).19 One challenge when trying to assess the impact of neuropsychiatric conditions on population health and dis- ability is that the diagnosis of mental health disorders is in part dependent on culture,20 and many disorders exist as part of a spectrum where the dis- tinction between what is classified as "normal" and what is classified as a "disorder" is blurry. Mental health disorders are known to be significantly underdiagnosed and undertreated worldwide. 21

2.3.D Injuries

An injury is physical damage to the body. An injury may be a fracture of a bone, a strain or sprain of a joint, a brain or spinal cord injury, wounds to the skin, or damage to internal organs. Injuries may be unintentional, such as a traffic accident, fall, bum, or drowning, or intentional. Intentional acts are further classified as self-directed violence (self-mutilation or suicide), interpersonal violence by family members, intimate partners, or community members, or collective violence such as war, mob violence, gang violence,

2.3 Classifying Disease 35

"fable 2"-6 Types of mental health disorders.

Type of Disorder

Disorders usually first diagnosed in infancy, childhood, or adolescence

Examples

" Developmental disorders such as mental retardation

" Learning, motor skills, and communication disorders

., Pervasive developmental disorders like autism and Asperger's

" Attention-deficit and disruptive behavior disorders like attention-deficit hyperactivity disorder (ADI--ID), conduct disorder, and oppositional-defiant disorder

., Tic disorders like Tourette's

Cognitive disorders "Alzheimer's and other dementias

Substance abuse disorders

Schizophrenia and other psychotic disorders

Mood disorders

" Alcohol abuse

.. Drug abuse with amphetamines, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidines, sedatives, hypnotics, or anxiolytics

" Schizophrenia

.. Delusional disorder

., Major depressive disorder (unipolar depressive disorders)

" Bipolar disorder

Anxiety disorders .. Panic disorder

Impulse-control disorders

" Obsessive-compulsive disorder (OCD)

" Posttraumatic stress disorder (PTSD)

" Anorexia nervosa

" Bulimia nervosa

.. Pathological gambling

Source: Information from Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV-TR). Arlington VA: American Psychiatric Association; 2000.

or terrorist acts 2~ 7).22 About two-thirds of injury deaths worldwide each year are from unintentional injuries and one-third from intentional injuries, with some variation between regions and countries 7,23

People living in poverty are at increased risk of injury because they are more likely than others to live, work, and go to school in unsafe envi- ronments, For example, low-income individuals are more likely to use

36 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

Table 2-7 Examples of types of injuries.

Unintentional Injuries

• Road-traffic injuries

• Falls

• Burns

• Drowning

Intentional Injuries

Self-directed violence

• Suicide

• Cutting

Interpersonal violence

• Poisoning • Spousal/intimate partner abuse

100%

80%

60%

40%

20%

• Child abuse

• Elder abuse

Collective violence

• War

• Terrorist acts

• Gang violence

USA South Poland Brazil China India Kenya Sierra Korea Leone

III War

III Violence

Ii1 Self-inflicted injuries

III Other unintentional injuries

D Drownings

Ii1 Fires

III Falls

III Poisonings

III Road-traffic accidents

Figure 2-7 Estimated proportion of injury deaths due to various types of injury in 2008.

Source: Data from The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011.

overcrowded and poorly maintained vehicles for transportation, to be pedestrians on crowded streets, to live in homes that are vulnerable to fire, and to have limited access to preventive health tools. 24 Environmental exposures to chemicals, like poisons, alcohol, smoke, and heavy metals, or

2.4 Sources of Health Information 37

to physical trauma, radiation, heat, cold, or allergens can also cause illness and injury, and some ofthese exposures are more common in low-income nations where there is limited access to clean water and trash removal, where food must be prepared over a fire, and where enforcement of safety laws is minimal. These injuries and exposures can cause immediate health problems, and they can also cause long-term disability and lead to the development of other health problems. For example, radiation from an industrial accident can cause cancer to occur years after the initial exposure.

Many injuries that are the result of accidents could have been prevented by the use of safety belts and child car seats in motor vehicles, helmets for cyclists, designated drivers who have not consumed alcohol, flame-resistant clothing, smoke detectors, fencing around bodies of water, swimming lessons, protective eyewear, safety harnesses when working at dangerous heights, and locked storage of weapons and ammunition, or any of the hundreds of other preventive safety measures that can be implemented by individuals, families, workplaces, and communities. 2S One goal of global health is to increase access to safety tools and encourage behaviors that reduce the risk of injuries.

Health information comes from a wide variety of sources: census data, vital statistics registries, surveillance systems, household surveys, health services records such as hospital patient files and insurance claims, and maps of the locations of health facilities. 26 Many types of data gathered as part of he~~ith are available online. That makes it possible for everyone to read, interpret, critique, and use the scientific research that informs global public health. These findings are most often disseminated through the web sites and annual reports of major govern- mental and nongovernmental health organizations and through academic journal articles.

Three of the best sources for basic disease information are the web sites of the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the u.s. National Institutes of Health (NIH). All three of these organizations provide easy-to-read and regularly updated fact sheets about hundreds of diseases. They also provide resources like health glossaries and image databanks. The websites of these and other trusted organizations are an excellent first place to go for information about disease symptoms, prevention methods, diagnostic techniques, and treatments.

38 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

Table 2-8 Selected annual publications with global public health information.

Report

Human Development Report

State of World Population

State of the World's Children

World Development Report

World Health Statistics

Source

United Nations Development Programme (UNDP)

United Nations Population Fund (UNFPA)

United Nations Children's Fund (UNICEF)

World Bank

World Health Organization (WHO)

For global health statistics, the best sources are often the annual reports of United Nations agencies (Table 2-8). These usually focus on a particular theme but provide a variety of country-level health and development indi- cators in statistical appendices. For disease-specific statistics, the reports of specialty organizations may be the best references. For example, the American Cancer Society (ACS) reports some global cancer statistics every year, as does the International Agency for Research on Cancer (IARC), which is part of the United Nations system. For critical health issues, such as new outbreaks of serious infections, the CDC's Morbidity and Mortality Weekly Report (MMWR) and the WHO's Weekly Epidemiological Record may be helpful.

Fact sheets, annual reports, and other summaries of research findings are called secondary sources because they provide "second-hand" information about a topic. The best way to find more detailed information about particu- lar research studies is to read primary sources such as original research reports published in academic journals. An abstract is a one-paragraph summary of the methods, results, and conclusions of a scientific investiga- tion. Abstract databases, including PubMed, which is freely available on the Internet, and SUbscription services purchased by libraries, can be used to find abstracts summarizingjoumal articles related to medicine and public health. The full reports that are summarized by these abstracts can then be found online or in a library. The articles from journals indexed in academic databases are peer-reviewed, which means that before the paper was pub- lished the manuscript was sent to experts in the field, who scrutinized the methodology and reviewed the results to make sure they seem reasonable.

References 39

The ability to find and understand relevant primary and secondary infor- mation is a critical tool for anyone working in or studying global health. Ideally, access to a variety of high-quality resources provides an evidence- based foundation for anyone seeking to create, implement, evaluate, or improve global public health policies and practices.

1. Look up the human development ranldng and the population size of a country not listed in Table 2-1 using the same references listed for the table. What do these two numbers alone tell you about the likely public health profile of the country?

2. How long do you expect to live? What factors did you consider when estimating your life expectancy? What events might occur that would cause you to significantly lower or raise your life expectancy?

3. When is incidence the best measure to use for assessing disease burden? When is prevalence a better measure to use?

4. Which of the risk factors listed in Table 2-2 are ones that affect a large proportion of your home community? What public health interventions might help reduce the burden of disease attributable to these risk factors in your home community?

5. What do you think will be the cause of your death? What would your likely cause of death have been if you had been born 100 years ago? How would your likely cause of death differ if you lived in a different part of the world today?

6. Create a brief disease profile for one of the many infections, diseases, or disabilities introduced in this chapter. What sources provide trusted background information about the symptoms of the disease and ways to prevent and treat it? What sources provide good statistical information about how many people worldwide are affected the condition? What can academic publications contribute to your profile?

REFERENCES

1. Mun-ay eJ, Frenk J. Health metrics and evaluation: strengthening the science. Lancet. 2008;371 :1191-1199.

2. Human development report 2012. New York: UNDP; 2012. 3. World development report 2011. Washington DC: World Bank; 201l. 4. World development report 2006. Washington DC: World Bank; 2005.

40 CHAPTER 2 MEASURING THE GLOBAL BURDEN OF DISEASE

5. Mathers CD, Murray CJL, Lopez AD, et al. Estimates of healthy life expectancy countries for 191 countries in the year 2000: methods and results. WHO Global Programme on Evidence for Health Policy Working Paper No. 38. Geneva: WHO; 2001.

6. World health statistics 2011. Geneva: WHO; 2011. 7. The global burden of disease: 2004 update. Geneva: WHO; 2008. 8. Jha P. Avoidable global cancer deaths and total deaths from smoking. Nat Rev Cancer.

2009;9:655-664. 9. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J.

Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373:2223-2233.

10. Bhutta ZA, Ahmed T, Black RE, et al.; Maternal and Child Undernutrition Study Group. What Works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371:417-440.

11. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011. 12. Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group.

Country trends in metabolic risk factors. London: Imperial College London; 2011. 13. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U; Lancet Physical

Activity Series Working Group. Global physical activity levels: surveillance progress, pitfalls; and prospects. Lancet. 2012;380:247-257.

14. World health statistics 2012. Geneva: WHO; 2012. 15. Cohen AJ, Ross Anderson H, Ostro B, et al. The global burden of disease due to outdoor

air pollution. 1 Toxicol Environ Health A. 2005;68: 1301-1307. 16. Lawes CMM, Vander Hoorn S, Rodgers A; International Society of Hypertension.

Global burden of blood-pres sure-related disease, 2001. Lancet. 2008;371:1513-1518. 17. Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, Clifford GM. Human

papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update.lnt 1 Cancer. 2007;121:621-632.

18. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.

19. Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV-TR). Arlington VA: American Psychiatric Association; 2000.

20. Summerfield D. How scientifically valid is the knowledge base of global mental health? BMl. 2008;336:992-924.

21. Demyttenaere K, Bruffaerts R, Posada-Villa J, et al.; WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. lAMA. 2004;291 :2581-2590.

22. Injury: a leading cause of the global burden of disease, 2000. Geneva: WHO; 2002. 23. The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011. 24. Laflamme L, Burrows S, Hasselberg M. Socioeconomic differences in injury risks:

a review of findings and a discussion of potential countermeasures. Copenhagen: WHO- EURO;2009.

25. World report on child injury prevention. Geneva: WHOIUNICEF; 2008. 26. AbouZahr C, Boerma T. Health information systems: the foundations of public health.

Bull World Health Organ. 2005;83:578-583.

Health research at its broadest encompasses everything from molecular and cellular biology to clinical research to population health. Most global health research focuses on the public health end of the spectrum. The goals of public health research include identifying and classifying new health problems, determining risk factors for disease, developing and testing new interventions for preventing or treating illness, evaluating the impact of health policies on health outcomes, and synthesizing existing knowledge.

is the study of the distribution and determinants of morbid- ity, mortality, and disability in populations. Epidemiologists and other public health researchers collect and disseminate data about the health-related conditions that occur in particular populations and the characteristics of the people who are most at risk for developing those conditions. This information helps clinicians to diagnose illnesses, prescribe appropriate therapies, and encourage healthy lifestyles for their patients. It also helps communities to set their own public health priorities and design and evaluate programs to address these issues, especially when a process caned cmnnlUlflit:\T·th:9SE:O. ,.,o,~"-;.'".>"."'"-''''O,, :re§earch is used. Research reports also inform the development of evidence-based policies and programs.

Several significant global health reports are released by major interna- tional organizations each month, and thousands of new global health-related

42 CHAPTER RESEARCH AND GLOBAL HEALTH

academic and professional journal articles are published each month. A basic understanding of health research methods makes all these resources- including the more than 500 references cited in this book-accessible to those seeking additional information about a particular health topic.

Health research follows a fixed set steps 1 Researchers start by identifying a focused study question and selecting an appropriate study design. They then work out the logistics of the study and collect data, which could take the form of interviewing people, running laboratory tests, acquiring documents for review, or other methods. After analyzing the collected data, the findings are disseminated through oral presentations and written publications.

The basic unit of population health research is the that collects new data from individuals drawn from a well-defined population, such as the students at one school or a sample of residents of one suburban area. Most primary studies are observational and simply ask participants to complete a questionnaire. Some primary studies are experimental ones in which researchers assign at least some of the participants to do something new, perhaps to start taking a daily multivitamin or to take a new drug for their health condition. When the results of primary studies are published, they are said to add to the literature on a particular topic. (A "',"'_'n"Vl.<~,'

also contributes to the body of knowledge on a topic by analyzing and reporting on existing data that someone else collected.) The summaries of these articles are often indexed in abstract databases such as PubMed that allow the contents of the manuscripts to be searched.

For global health, it is often important to have a worldwide perspective on disease incidence and prevalence rates, risk factors for disease, and other health information. A seeks to identify all the primary (and secondary) studies that have been published on a particular and to summarize what those studies say, These systematic reviews and

Identify study

question

S.e1ect .. study .

approa9h

3~1 The research process.

Design study and

collect data

Analyze data

. Report finding$

Source: Reproduced from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

3.3 Observational Study Designs 43

meta-analyses provide a comprehensive picture of what is known about a particular issue, and the findings and estimates from these studies can be used to predict health status in populations for which no data are currently available and to forecast future situations. Most of the global health reports published by the World Health Organization and other international agen- cies are based on primary studies (including country-level surveillance reports) and on meta-analyses that synthesize primary studies. These reports provide comparable data from around the world that can be used by poli- cymakers, public health professionals, and others to foster improved health in their communities and countries.

Most population-based public health research uses an observational study design. An simply observes what people are doing or asks about what they have done in the past. No intervention is assigned to participants. The goal is to learn about a population as it is. ,~M-'l'-""C" seek to describe the members of a population, the prevalence of risk factors within that population, or the rate of disease within that population. Descriptive studies often seek to answer questions about person (who?), place (where?), and time (when?). §tudie§ aim to understand the associations between risk factors and disease within a population and to answer "why?" questions.

A §Hlc'Vey, also called a (Toss-sectional suney, can be used to get a snapshot of a population's health status at one point in time. The research plan is fairly simple: recruit a representative sample of the popu- lation the researcher wants to know about, ask the participants a series of questions, and then analyze the collected data to see what proportion of the population reported various characteristics. The questionnaire can cover a wide variety of topics, including demographics (such as the age, sex, house- hold income, and educational level of the participant), risk behaviors and other risky exposures, and illnesses and disabilities. The survey instrument can also include "KAP" questions about knowledge, attitudesibeliefs, and practicesibehaviors.

Prevalence surveys are one of the most common study designs used in public health research. They are often used as part of community needs

44 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

assessments, and they are also used for conducting program evaluations. They are especially useful when there are time and budget constraints, because data can be collected quickly and inexpensively.

There are two key cautions about conducting and critically assessing cross-sectional surveys. First, it is very important for prevalence studies to recruit participants who are truly representative of the population the researchers say they want to examine. For example, a study about the health of women in a community should not be limited to including only women who are currently pregnant, because that recruiting strategy would system- atically exclude older women who are of post-reproductive age. And a study about the health of college students should not recruit only students who are members of sports teams at the school, because those students are likely to be fitter than the general student body. Second, no conclusions about causal- ity can be made from cross-sectional data, because all the questions about exposures and diseases are asked at the same time. For example, a cross- sectional survey of chewing tobacco use and dental cavities among a group of 1000 high school students might find a significantly higher prevalence of cavities among people who use chew, but that would not prove that chew caused cavities nor would it prove that cavities cause people to chew. This type of survey cannot show whether the chew or the cavities happened first.

3.3.B Case Series

A case series looks at the characteristics of a group of people who all have the same disease (or all had the same exposure). (A case study is a description of one patient. A case series describes two or more patients.) Most case series studies are written by and for clinicians, and most summa- rize the information in the medical records of people who were treated at a particular hospital for a particular condition. The goal of a case series may be to understand the demographic and other characteristics of people with a particular disease, to describe an unusual presentation of a disease, or to clarify the typical progression of a disease. Because a case series does not include a comparison group of healthy people, it is not possible to examine risk factors for the disease.

3.3.C Case-Control Studies

Case-control studies recruit people with a disease (cases) and similar people who do not have that disease (controls) so that their past exposures can be compared. After confirming that a participant has the disease of

33 Observational Study Designs 45

interest or does not have the disease, the participant is asked about his or her health behaviors (such as diet, physical activity, tobacco use, and alcohol use now and in the past), environmental exposures, and health history. After a sufficient number of cases and controls have completed the questionnaire, statistical analysis is used to identify the exposures that were reported more often by cases than by controls.

Case-control studies are ideal for learning about rare diseases. They can also be helpful for identifying past exposures might increase the risk of disease, but the results of case-control studies must be interpreted cautiously because participants may have difficulty accurately recalling exposures that took place years or even decades before the study.

The most common way to look at the association between an exposure and a disease outcome is to create a 2. 1, table that has two rows for expo- sure status and two columns for disease status. Each individual in the study population is classified into one of the four groups created by the 2 X 2 table-exposed and diseased, exposed but not diseased, not exposed but diseased, and not exposed and not diseased. The count of the number of indi- viduals in each of the four groups is filled into the cells of the 2 >< 2 table, and various measures of association can then be calculated from those values.

The typical measure of association between an exposure and an out- come in a case-control study is the odds ratio. This is the same type of measurement used in betting If someone thinks that a horse has a 25% chance of winning a race (and a 75% chance of losing), then the odds on the horse are 25:75, which can be simplified to 1:3 or 1/3 or O.33-one chance of winning compared to 3 chances of losing. The odds

compares the odds of a case having a history of a particular exposure to the odds of a control having been exposed to the potential risk factor An OR near 1 means that there was no association between the disease and the exposure in the study population, because cases and controls were equally likely to report the exposure. An OR greater than 1 indicates that people with the disease were more likely than people without disease to have a history of the exposure, which implies that the exposure was risky. An OR less than 1 indicates that cases were less likely than controls to have a history of the exposure, which implies that the exposure was protective.

Because a relatively small number of people sampled from a larger population cannot exactly describe the population as a whole, ORs and other statistical measures are often reported using confidence intervals. A % c:onfidl2;nc~ for an OR can be interpreted as saying "based on the sample of people the researchers took from the larger population, we can be 95% confident that the true OR in the

46 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

100%

Figure 3-2 Odds. Source: Reproduced from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

Figure 3-3 Case-control study analysis: odds ratio (OR). Source: Reproduced from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

3.3 Observational Study Designs 47

population as a whole is somewhere within this range of possible ORs" If the entire confidence interval is greater than 1, the result

is said to be statistically significant, and the conclusion is that the expo- sure appears to be risky. If the entire confidence interval is less than 1, the result is also statistically significant, and the conclusion is that the exposure appears to be protective. If the confidence interval overlaps 1, it means that there is not strong evidence that the exposure is risky or protective, and the conclusion is that there is no statistically significant association between the exposure and the outcome in the study population. In the example shown in Figure the OR and 95% confidence interval is 0.56 (0.32, 0.93). Because the entire range is less than 1, the association between the exposure and disease is said to be statistically significant, and the conclusion is that cases were much less likely than controls to have had the exposure.

A cohort is a group of similar people, and cohort recruit a group of similar people and follow them forward in time. At the start of the study, the researchers ask all of the participants about a variety of health behaviors and other exposures and characteristics, and they confirm that

Figure 3~4 Case-control study analysis: 95% confidence interval for the OR.

Source: Adapted from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 201 2.

48 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

Figure 3-5 Example of a case-control study.

no one enrolled in the study already has the disease outcome of interest. The participants are then tracked for months or years, so that researchers can count the number of people who develop the disease or disability of interest. Statistical analysis is used to compare the rate of incident (new) disease among those with a particular exposure and those without that exposure.

Because the data collected at the start of the study can prove that an exposure existed before the onset of disease, cohort studies are very help- ful for establishing whether an exposure causes a disease. Cohort studies are also useful for measuring the incidence of new disease in a population. The population studied can be a representative sample of a whole com- munity or even a whole country. For example, the Framingham study has been following thousands of residents of one town in Massachusetts since 1948,2 and the Whitehall studies have followed British civil servants from all occupational classes since the 1960s.3 Another option is for people with an unusual exposure, such as an exposure to a particular industrial chemi- cal, to be recruited and tracked for a long time so that researchers can study the impact of that rare exposure on the participants' future health status.

Two of the most common measures of association for a cohort study are the rate ratio and the attributable risk. The incidence rate ratio (also called the risk ratio or relative risk, or simply shortened to RR) is calcu- lated by dividing the rate of incident disease in the exposed cohort by the rate in the unexposed cohort (Figure 3-6). An RR near 1 means that exposed and unexposed participants were equally likely to develop the disease during the study period. An RR greater than 1 indicates that the exposure was associated with increased risk of disease. An RR less than 1 indi- cates that the exposure was protective. Confidence intervals can be used

3.3 Observational Study Designs 49

3~6 Cohort study analysis: rate ratio (RR).

Source: Reproduced from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

to show the level of certainty about the RR in the larger population from which participants were drawn The ]['2!te (also

subtracts the rate of disease in the unexposed from the rate of disease in the exposed. If the exposed and unexposed populations were similar except for their exposure status, then this difference in disease rates represents cases of disease among exposed people that would not have occurred if they had not been exposed

In the example shown in the RR and 95%

3-:7 Case-control study analysis: 95% confidence interval for the RR.

Source: Reproduced from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

50 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

Figure 3-8 Cohort study analysis: attributable risk (excess risk).

Source: Reproduced from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

confidence interval is 2.00 (1.46, 2.74). Because the entire range is greater than 1, the association between the exposure and disease is said to be statistically significant, and the conclusion is that the exposure is a risk factor for the disease. The attributable risk percent is 50%, which means that half of the cases of disease among the exposed participants could have been prevented by removing the exposure.

3.4 EXPERIMENTAL STUDIES

Experimental studies, sometimes called intervention studies, are studies in which the researchers assign participants to receive a particular exposure. Experimental trials are the best study design for assessing causation, because the researchers intentionally subject participants to an exposure and then see what happens afterward. But because the researchers may be placing participants at risk of unexpected and potentially serious adverse outcomes, there are some special ethical concerns associated with experimental studies.

3.4 Experimental Studies 51

::'P} Example of a cohort study.

Some studies are deemed too risky to be conducted. Those that are approved are closely monitored by research ethics committees.

Some experimental studies are CH;;lksl of a new medication, a new vaccine, another new medical product, or some other intervention. Most clinical trials use a randomized controlled tirial design in which some people are assigned by chance to the active intervention and others are assigned by chance to a comparison group. The comparison may be a placebo, like a sugar pill or saline injection, or may be an active control such as the best drug already on the market or a lower dose of the new medication being tested. Most clinical trials are double which means that neither the participants nor the people assessing the participants' health outcomes know whether a palticipant is receiving the trial drug or a placebo. That way neither the participants nor the examiners will be tempted, even subconsciously, to find a better outcome in a patient who they know is taking the new drug.

The most common outcome measure for an ReT is the of the intervention, which measures the ability of the intervention to produce

52 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

Figure 3-10 Experimental study analysis: efficacy. Source: Adapted from Jacobsen KH. Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

the desired effect. For example, a vaccine trial with a placebo control will evaluate how well the vaccine prevented infection by comparing the rates of infection in the vaccine group and the placebo group (Figure 3-10).

Most new vaccines, medications, and other pharmaceutical agents undergo several rounds of testing before the product is released to the public. The first phases of the study test the safety of the product in small numbers of people. Later phases recruit hundreds or thousands of people to ensure the safety and effectiveness of the new product. Ongoing safety monitoring continues after the product is in wide use.

3.5 RESEARCH ETHICS

Nearly all health research projects that involve contact with people or access to identifiable personal information are supervised by ethics commit- tees, commonly called Institutional Review Boards (IRBs) or Research Ethics Committees (RECs). Review boards will not approve studies that do not meet the three main ethical considerations of health research: benefi- cence, respect for persons, and distributive justice.

Beneficence means that the study should be beneficial for the partici- pants and for their communities. This call to do good is often paired with

3.5 Research Ethics 53

nO<U11(!1:Iliell!cenCi(:, from the root words for nonbadness, which call for the study to do no harm.

Respect for persons demands that all potential participants have the 1]utmlmny to choose whether they want to volunteer to participate in a study and that all potential participants are given all the information they need to be able to make an informed decision about whether to participate. Candidates for a research study should be told about the goals of the study, the potential risks and benefits of participation, the study procedures, the time requirements of participation, and the process for withdrawing from the study if they change their mind about participating. The process of sharing information and agreeing to participate is called cm1l.§ent No one should feel pressured to participate in a research study. Respect for persons also requires researchers to keep the safety of participants as their top priority and to protect the privacy of participants and the confidentiality of the information participants choose to disclose.

aims to ensure that the populations that bear the risks of research participation have access to the benefits of that research. For example, this means that a community that took on the risk of vol- unteering to test a new medication or a new vaccine should also have the benefit of having access to that product after it is approved and marketed.

Adherence to these standards prevents the types of research misconduct that occurred in the mid-20th century when medical experiments were often conducted without participant consent. One of the most widely known examples from the United States is the Tuskegee Syphilis Experiment, which was conducted by the U.S. Public Health Service in Alabama for 40 years beginning in 1932.4 Nearly 400 African-American men with late-stage syphilis were offered free medical care by doctors who were conducting a study on the progression of the disease. The men were not told that they had syphilis and many were not treated with antibiotics even after penicillin became the standard cure for the infection in 1947. Treatment was provided only after a major newspaper reported on the study in 1972. By that time many of the men had died of syphilis and many of their wives had been infected.

In order to protect the "human subjects" of research, new and ongo- ing research projects must be approved by an independent IRB in each country where study data will be collected. Research ethics committees will not approve studies that they deem to be unreasonably dangerous, poorly planned, or unnecessarily targeting members of a vulnerable popula- tion. After approval, the IRBs monitor ongoing studies. Researchers must seek prior approval for any changes they want to make to their research

54 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

protocols, and they must immediately report any adverse event to the IRBs that are overseeing the project. These rules help researchers to design and implement high-quality research plans, and they help to ensure the protec- tion and safety of all research participants.

3.6 SYNTHESIS STUDIES

Some research investigations synthesize the results of dozens or hun- dreds of previous primary studies. By combining and analyzing the results of multiple similar research studies from different parts of the world or vari- ous points in time, these tertiary analysis studies provide a comprehensive summary of the scientific literature on a particular topic, a foundation for projections about health problems and needs, and new insight about risk factors for particular diseases.

3.6.A Correlational Studies

A correlational study, sometimes called an ecological study, uses numeric data about a particular exposure and a particular health outcome from several populations to look for trends. The results of correlational studies are often displayed using a scatterplot. For each population, a point is placed on the graph by using the value for the exposure in that population as the x-coordinate and the value for the health outcome in that population as the y-coordinate. After all the points are plotted, a line that represents the best fit to the points is added to the graph.

The value of the correlation coefficient, r (which is often reported as r2), measures how well the line predicts the location of the points (Figure 3-11). An r near 1 means that all of the points fall almost exactly on a line, so if the exposure level in a population is known, the outcome can be predicted with a high level of certainty. An r near 0 is extremely weak and means that the line has no predictive value. In other words, when r is close to 0, the exposure is not associated with the disease outcome. An rnear 0.5 indicates a moderately strong correlation.

The slope of the line shows the direction of association. A positive value for r indicates a positive slope (one that goes up from left to right) and signifies that an increase in the rate of the exposure is associated with an increase in the rate of the outcome. For example, a study of 37 countries found that countries with greater income inequalities also had greater rates ofbullyirrg among middle school students (r = 0.62).5 A negative value for

3.6 Synthesis Studies 55

Positive Slope l\legative Slope

r = 0.96 r = 0.04 r= -0.47

3-11 Analysis for a correlational study: correlation.

r indicates a negative slope and shows that an increase in the exposure rate is associated with a decrease in the outcome rate. For example, a study of 43 African countries found that countries with a higher proportion of adults who could read had a significantly lower proportion of women who died in childbirth (r == -0.52).6

These two examples highlight a key aspect of ecological study design: most ecological studies are designed to examine population-level exposures and outcomes, like income inequality, literacy rates, air quality, and mater- nal mortality rates. Ecological studies are not used to test individual-level correlations. Thus, the results of ecological studies that use population- level data can be applied to populations but cannot necessarily be applied to individuals. For example, if an ecological survey using data from dozens of cities shows a strong positive correlation between the number of tanning beds per 1000 adults and the number of new skin cancer diagnoses each year per 10,000 adults, this finding would not prove that the individuals who used tanning beds were the ones whowere diagnosed with skin cancer. It is possible (though unlikely) that none of the individuals who use tanning beds developed skin cancer. The ecofogka,! describes when population- level correlations are incorrectly interpreted to be measures of individual risk. However, even with this limitation, ecological surveys can be a very helpful first step in testing a hypothesis about a possible risk factor for disease.

tiYi~t\e)i11~tac lnJ',Jj",',!f]r,}, identify as many articles and reports about a particu- lar topic as can be found, then check each one to see if it meets the predefined criteria for inclusion in the analysis. Information from each eligible article is extracted and compared with the other studies in order to paint a compre- hensive picture of what is known (and what is not known) about the topic.

56 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

For example, a systematic review might show strong agreement in the literature about a particular exposure being a risk factor for a specific dis- ease. Or the review might suggest that a particular exposure does not appear to increase the prevalence of a disease. Or a review might determine that the previous studies have mixed results and no consensus can be reached about the association based on the current scientific literature. (To ensure a fair conclusion, systematic reviews usually consider the potential effects of publication bias on their findings. Publication bias occurs when studies that find a statistically significant result are more likely than "null result" studies to published.)

When the study designs and the statistics used for each of the included studies in a systematic review are quite similar, it is sometimes possible to pool the results from the independent studies to create one summary statisti- cal measure. This combined statistical analysis is called a meta-analysis.

3.6.C Forecasting and Modeling

Mathematical models can be used to estimate disease rates in populations lacking good data and to predict future health trends. For example, global burden of disease studies generally start with a systematic review of the disease of interest, and usually find incomplete data for many countries in the world. A mathematical model that incorporates the information that is available for a country (such as the distribution of the population by age) and estimates of morbidity and mortality from other countries with similar geographic and socioeconomic profiles can provide a good foundation for understanding the likely health profile of the understudied country. Similarly, if health and demographic data from several points in time in one country or world region are added to a model, researchers can create projections about the likely health situation in that area in 10, 25, or even 50 years. Models can also be modified to simulate the short-term and long-term effects of public health interventions and other population-level changes.

3.7 INTERPRETING STATISTICS

The only way to have a 100% accurate measure of health in a population is to collect data from every individual in that population. However, this is rarely done for large populations because of time and money constraints. Instead, a small proportion of the population is recruited for the study, and statistical tests are used to provide estimates of the health status in the whole population based on measures taken from the sample population.

3.7 Interpreting Statistics 57

F'igme 3· .. 12, shows an example of sampling. Of the 100 people in the population from which participants will be sampled, 32 are obese. If 10 individuals are sampled at random from that population, it is likely that the prevalence of obesity in the sample population will be 20% or 30% or 40%, something relatively close to 32%. However, some samples will, by chance, have a prevalence of 80% or 90% or even 100%. So a sample of 10 will not allow a high level of precision about the prevalence rate in the total population, even though it can provide a reasonable rough estimate.

The uncertainty about what the sample measure says about health in the larger population from which participants were drawn can be captured in a 95% confidence interval (95% CI) similar to the ones used for ORs and RRs. For example, the obesity prevalence estimate and its 95% CI for a sample of 10 individuals may be 30% (8%, 62%). This means that based on one sample of 10 people, we are 95% confident that the true prevalence in the larger population is somewhere between 8% and 62%. That range does indeed capture the 32% that is the true prevalence. (There is a 5% chance that this sample happened to be extreme, and that the 95% CI does not include the true value of the prevalence.) If a narrower CI is desired, then a larger sample popUlation must be used. For example, if 50 individuals participate in the study instead of 10, then the estimate ofthe prevalence might be 34% (22%, 48%). That would mean that based on one sample of 50 people we are 95% confident that the true prevalence is somewhere between 22% and 48%. If more people are sampled, the 95% CI would become even narrower and closer to the true value of 32%.

100 Total People in the Population

o~oo~ooooo OOOOOOeOf!lO

oo~oo 00080

OO~@O@OOO~ ~O~OO ~oooeoo~oo I-----l>-I'li& ~ @oe~o~o~@O OO~OO OO~OOOOOO@ ~O~OO OOOOOO~O~O O •• O.OO~O~ ~OOO@

000980000 O~OOOOOO~O O~OO~

OOO~O 32% are obese

3-12 Sampling from a popUlation.

Samples of groups of 10 people from the population will come close to 32%, but may not be exactly 32%,

58 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

A p-value (or probability value) is another measure of uncertainty. P-valuesare usually used with statistical tests of difference to indicate how likely it is that a difference exists between two or more populations. For example, a t-test can be used to see if there is a difference in the mean age of men and women who participated in a cross-sectional study, and a Chi-squared test can be used to see if there is a difference in the proportion of adults with diabetes in four different neighborhoods in one city. The p-value for these tests gives the estimated probability that, given the number of people in the sample, an even bigger difference between the groups than the one found for the sample might occur by chance even if there really was no difference between the groups being compared. Just as a larger sample size results in a narrower confidence interval, a larger sample size makes it easier to have a small p-value. A larger sample gives the test greater statistical power, a better ability to detect a difference between two or more groups when the groups really are different.

A small p-value (usually less than 0.05, or 5%) means that the statistical test found that it is unlikely that a larger difference between groups would occur by chance. Tests that produce p-values less than 0.05 are said to have statistically significant results and are deemed to show a difference between the groups being compared. For example, if a t-test comparing the mean ages of men and women has a p-value of 0.02, there is only a 2% likelihood that such an extreme difference in mean age would be observed by chance if there was really no difference between the popula- tions. Because it is so unlikely that the apparent difference in mean ages of men and women was due to chance, the conclusion for this test is that the mean ages for men and women in that population are different. If the t-test has a p-value of 0.68, there is a 68% likelihood that an even big- ger difference could be observed by chance if samples were drawn from populations with the same mean age. In this situation, the conclusion is that the means are not different. Other examples of p-value interpretation are shown in Table 3-1.

Knowing the meaning of CIs and p-values allows a reader to interpret almost all statistical results. A p-value of less than 0.05 means that a difference exists. A larger p-value means that no difference has been observed. A CI provides a range of likely values for a measure in a popu- lation, and that range gets narrower as the sample size increases. The CIs for ratios (like ORs and RRs) are centered around 1; if the CI does not include 1, then there is a difference between the two populations being compared by the ratio.

3.8 Critical Reading 59

T",bie 3~1 Examples of p-value interpretation.

Is the p-value "extreme"

Goal atTest p-value (p < 0.05)? Conclusion

To compare mean ages 0.13 No The mean age of the of men and women populations is not

different.

To compare mean scores 0.002 Yes The mean test scores by on a test for children in grade are significantly grades 1, 3, and 5 different

To compare the 0.43 No The distribution of proportion of employees responses by the various in different divisions of groups is not different. a company who walk or bike to work each day

To compare the 0.03 Yes The proportions of people prevalence of diabetes with diabetes in the two in two cities cities are significantly

different.

Several characteristics of good public health and medical research reports are listed in Table 3-~2. Beyond these factors, there are several other impor- tant considerations for readers who are assessing and applying the results of published studies. These cautions include bias, measurement validity, and target populations.

is a systematic error in study design, data collection, or data analysis that might create a difference between what the study intended to measure and what it actually measured. Bias of any type can lead to an overestimation or an underestimation of the association between an exposure and an outcome. bh1§ occurs when the people who participate in a study are not representative of the intended sample popu- lation. One example of selection bias is VOhlinii£:€T which occurs when people who volunteer to be part of a research study turn out to be different from the desired sample population, perhaps because they are systematically healthier or less healthy than the population as a whole.

60 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

Table 3-2 Characteristics of good public health and medical research reports.

• The article has been peer-reviewed and published in a respected journal or by a trusted organization.

• The population studied is clearly defined and the number of participants in the study was reasonably large.

• An appropriate epidemiological study design was used (with a control group, if required).

• The methods used to measure exposures/interventions and health outcomes are explained in detail.

• The results of statistical tests are presented using easy-to-read charts, graphs; and tables.

• The relationship of the new study to previous studies is discussed, and many other articles are cited.

• The strengths and limitations/biases of the study are acknowledged and discussed.

• The conclusions seem reasonable and are based on the new results.

• The article is well written and follows a logical outline (usually Introduction/ Background, Methods, Results, Discussion/Conclusion).

• The article states that the study was approved and overseen by an ethics review committee, and there are no obvious conflicts of interest that may have influenced the findings.

Information bias occurs when incorrect infonnation is given to research- ers. For example, recall bias may happen when participants do not accu- rately recall past events. When there is differential recall-say, when people with cancer strain to recall any potentially harmful past exposure but people in the control group of a case-control study are not similarly motivated to remember past exposures-the results of a study may be inaccurate. Bias can be avoided or minimized when a study is carefully designed, conducted, and analyzed. The discussion sections of articles usually include an explanation of the limitations of the study and the possible sources of bias (as well as potential issues related to confound- ing, effect modification, or other scenarios that could affect the results). Readers can also make their own evaluations about whether bias in a study may have influenced the findings.

Validity asks how well a test measures what it is supposed to measure (internal validity) and how well a study measures the true situation in a pop- ulation (external validity or generalizability). A test should be accurate (valid), which means that it gives the actual values of height, blood pressure,

3.9 Evidence-Based Global Health

or some other measure. A test should also be which means that when the test is given several times to the same person the results are consistent. Most global health research articles provide details in their methods sections about their survey instruments (questionnaires), clinical and laboratory tests, and other assessments. Readers should check to be sure that the questions used for a survey appear to accurately capture the exposure of interest. Self-reported measures (like "how many calories did you eat today?" and "how many miles did you walk today?") may not be as accurate as observed measures (such as having a researcher quantify the actual portions of various foods eaten during the day and using a pedom- eter to record the number of steps taken). Additionally, different types of questions may yield different responses (such as "how many servings of vegetables did you eat today?" versus "how many servings of vegetables do you eat in a typical day?").

A third consideration relates to the populations to which the results of a study can be applied. The conclusions of a study that included only male participants between 20 and 24 years of age should not be applied to women ages 80 to 89. The conclusions ofa study of women living in California probably do not apply to women living in Malawi. The conclusions of a study of nonsmokers should probably not be applied to smokers. Results from tests done in rats do not necessarily apply to humans. Caution should be used when applying the results of any study conducted in one place at one point in time to another population.

Clinicians often use a process called rnedidne to guide them as they seek to make the best decisions about how to care for their patients. The goal of EBM is to use facts rather than anecdotes or ideology to make clinical decisions. Like EBM, evidence-based public health and evidence-based global health require a careful and critical review of the literature prior to implementing any intervention 7 The goal of this review process is to learn what has worked for others and what has not worked. There is no need to "reinvent the wheel" when the global health literature is fun of examples of successful public health programs and policies. There is also a substantial benefit to learning from the mistakes others have made and not repeating them. Ideally, evidence- based global health promotes the cost-efficient and effective use oflimited health resources to solve public health problems. The tools in this chapter

62 CHAPTER 3 RESEARCH AND GLOBAL HEALTH

Figure 3-13 The public health approach.

Source: Adapted from Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye 0, editors. Injury surveillance guidelines. Geneva: WHO; 2001.

provide the foundation for conducting a valuable analysis of any global health concern or intervention. It is not an overstatement to say that health research saves lives.

3.10 DISCUSSION QUESTIONS

1. Look at the health webpage for a popular Internet news site. What topics are covered? How many of the stories present the results of a research project?

2. Would you participate in a health research study? Why or why not? Would your answer be different for an observational study and an exper- imental study?

3. Use PubMed or another abstract database to find an academic journal article on a health topic of interest to you. Read the article to find the answers to these questions: (a) What was the main study question?, (b) Who participated in the study, where did it take place, and when was it conducted?, (c) What study design was used?, and (d) What was the answer to the main study question?

4. Look up the most recent issue of the State of the World's Children or another United Nations report and examine the statistical annex. What sources of data contributed to these tables?

5. Find a recent news story from the popular press about a newly released health research report. Look up and read the scientific article on which the news report was based. Was the news story accurate? Did it leave out any critical information?

6. How have the results of health research studies contributed to improving your quality of life?

7. How do the results of health research studies contribute to improving global health?

References 63

1. Jacobsen KH.Introduction to health research methods: a practical guide. Sudbury MA: Jones & Bartlett; 2012.

2. Splansky GL, Corey D, Yang Q, et al. The Third Generation Cohort of the National Heart, Lung, and Blood Institute's Framingham Heart Study: design, recruitment, and initial examination. Am J Epidemiol. 2007; 165: 1328-1335.

3. Marmot M, Brunner E. Cohort profile: the Whitehall II study. Int 1 Epidemiol. 2005 ;34:251-256.

4. White RM. Unraveling the Tuskegee Study of Untreated Syphilis. Arch Intern Med. 2000;160:585-598.

5. Elgar FJ, Craig W, Boyce W, Morgan A, Vella-Zarb R. Income inequality and school bullying: multilevel study of adolescents in 37 countries. J Adolesc Health. 2009;45:351-359.

6. Alvarez JL, Gil R, Hernandez, Gil A. Factors associated with maternal mortality in sub-Saharan Africa: an ecological study. BMC Public Health. 2009;9:462.

7. Buekens P, Keusch G, Belizan J, Bhutta ZA. Evidence-based global health. lAMA. 2004;291 :2639-2641.

8. Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye 0, editors. Injury surveil- lance guidelines. Geneva: WHO; 2001.

Income, education,Qccupation, . . determinants of socioeconomic position have a signijicantimpacton health status and ·theability ... !o··.access healthcare· .. services.Culture.·(nfluences healthbeliefsandbehaviorsand shapes .decisionsabout when and wheretoseekhealth·care.

SoeioeconOInic ~riahm or sodoeco:rwliilk indi- cates an individual's (or family's) standing in a society based on social, economic, and educational characteristics. There is no one measure of SES, but proxies such as ownership of various assets (like a house, car, bicycle, television, radio, or livestock), occupation, amount and type of education, residential area, and other social and economic characteristics can be used to evaluate a person's relative position in a community or larger population group.

Three of the key components that contribute to the socioeconomic status of an individual or household-economic status, occupational status, and educational status-are inextricably linked to each other and to health status Any intervention aimed at one of these three categories will likely impact the others. New reading skills may lead to a better job. Increased job skills may lead to a higher hourly wage. Extra income may be used to pay for additional training. And anyone of these improvements can lead to increased health.

Income, employment, education, social class, sex, race, ethnicity, and other living conditions that influence health status and access to health ser- vices are collectively called the soda!; These factors can be summarized using the acronym PROGRESS, as shown in ~fab[e 4~1, 1

66 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

Education/ Literacy

HEALTH

Income/ Wealth

Employmenil Occupation

4-·] Socioeconomic status and health.

Tf'lble 4-1 PROGRESS-Plus list of the social determinants of health.

P Place of residence (rural/urban; particular state or province; housing characteristics)

R Ethnicity

o Occupation (and employment status) G Gender (male/female/other)

R Religion

E Education

S Social capital (neighborhood, community, and family support)

S Socioeconomic position (income, wealth, and other measures)

Age

Disability (physical or mental disability) Plus

Sexual orientation

Other vulnerable groups

Source: Adapted from Kavanagh J, Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus. Equity Update. 2008;2:1-3.

Children and adults who have low socioeconomic status (either in terms of absolute poverty or relative poverty compared to neighbors) tend to have significantly reduced health status compared to those from wealthier socio- economic groupS.2 These differences in health status between population

4.1 Social Determinants of Health 67

groups are called health and one of the key goals of global public health is to reduce health disparities by increasing the health status of disadvantaged populations.

The two most common ways of measuring the economic status of a house- hold are income and wealth. IncoIn(o is the amount of take-home pay earned by household members in a given time period. Wealth is the accumulated worth of the household's resources and can include a house, car, television or radio, livestock, and other consumer goods. Low-income households generally have very little wealth, so they have few resources to draw on when someone in the household develops a severe illness or disability.

About 1.4 billion people worldwide-l in 5 people-survive on less than the international poverty line of $1.25 per person per day 4_2).3 Many of the poorest households try to grow enough as subsistence farmers with a small plot of land to feed all the household members. Others are the urban poor, who often live in informal settlements with no amenities. Poverty impacts the type of dwelling a household lives in (which can be unstable, unventilated, and/or built with harmful materials), how crowded the home is (which can facilitate spread of infectious diseases like tuberculosis),

100~------------------------------------,

80+------------------------------------------------4

60+-------------------------------------------------1

40+--------------------------------

20+--------------------------------

o+-----.-----,,-----,-=~_,-

USA South Poland Brazil China India Kenya Sierra Korea Leone

4~2 Percentage of the population living on less than .25 per day, the international poverty line, between 2000 and 2009.

Source: Data from Human development report 2011. New York: UNDP; 2011.

68 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

and whether it is in proximity to schools, healthcare facilities, public trans- portation, waste dumps, and clean water sources.

Poverty is often linked to an unhealthy living environment. Many poor communities do not have a source of consistently safe drinking water, properly installed latrines, or enough water to practice good hygiene, so the risk of contracting an infection is greatly increased. In some places, dwindling availability of wood for fuel limits the ability of households to boil water and cook food. And without electricity for refrigeration it is difficult to store food safely. In rural areas, the lack of infrastructure for communication (such as telephones and radios) and transportation makes it difficult to access health education and health care. Furthermore, poor households may not have money for disease prevention, such as the pur- chase of insecticide-treated bednets for malaria, because they must dedicate all income to immediate survival needs like food, housing, clothing, and emergency medical care.

Poverty affects the health of people of all ages. For example, Figure 4-3 shows that children of relatively poor families have a much lower chance of survival than children of relatively wealthy families. 4- 6 Low-resource

250.----------------------------------.

200+------------------------

150+------------------------

100

o India

(2005-2006) Kenya

(2008-2009) Sierra Leone

(2008)

III Poorest 20%

III

o Middle 20% III

III Wealthiest 20%

Figure 4-3 Comparison of mortality rates of children less than 5 years old per 1000 live births, by wealth quintile.

Source: Data from India: DHS, 2005-06-final report. Calverton MD: International Institute for Population Sciences and Macro International Inc.; 2007 Sep.; and Kenya: DHS, 2008-09-final report. Nairobi and Calverton MD: Kenya National Bureau of Statistics and ICF Macro; 2010 Jun.; and Sierra Leone: DHS, 200S-final report. Freetown and Calverton MD: Statistics Sierra Leone, Ministry of Health and Sanitation, and ICF Macro; 2009 Jui.

4.1 Social Determinants of Health 69

households must make healthcare decisions very carefully and consider all the costs of health care, including transportation to a healthcare facil- ity, food for the patients and caregivers (as many hospitals do not provide food for inpatients), fees for seeing clinicians, the price of medications and supplies like bandages, and lost wages for the patient and caregiver. When people from poor households decide to seek medical attention they may receive substandard care because they have to seek care at an under- funded, understocked, and understaffed clinic. Hospitals that primarily serve the poor rarely have highly trained specialists on staff and may not have the support staff and technology to offer advanced care.

Wealthier people generally have better access to advanced health care when they are sick. They can afford the best diagnostic tests and the best therapies, and they have the resources to seek care for relatively mild conditions that if untreated could develop into severe problems. And because wealthier people have better access to good nutrition, work jobs that are less dangerous, and have usually had previous inju- ries and infections treated, they are usually in better overall health than poorer people. Thus, income and wealth directly contribute to enhanced health status.

Employment of at least one wage earner is generally critical for keeping a household out of poverty. In addition to income, employment often pro- vides health insurance, compensation for on-the-job injuries, and sometimes also housing, food allowances, and schooling for children of employees. These benefits can have a significant and positive impact on the health of workers and their families.

However, not all jobs are equally beneficial to health. People with limited job skills often have the most dangerous jobs, receive little compensation for their labor, and have little or no job security. Injured or ill workers may not receive adequate treatment for their conditions because they cannot afford to take time off to see a doctor or to recuperate at home, and because they cannot afford to pay for health care. Manual laborers have higher all-cause mortality rates than skilled nonmanual workers, and much higher mortality rates than professionals. 7 Men who do manual labor are more likely than nonmanual workers to die from injuries, some of which are job related, and are also more likely to die of heart disease, stroke, lung diseases, gastrointestinal diseases, and cancer. 8

70 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

Being unemployed or underemployed is also associated with reduced health status. Unemployed women and men who are healthy enough to be actively seeking work have higher rates of physical and mental illness than working people of the same age. 9,10 Unemployed working-age adults also have significantly higher suicide rates and all-cause mortality rates than employed men and women. 11

Formal education and the ability to read are both correlated with a variety of measures of health. is usually defined as functional literacy, the ability to understand written words well enough to complete normal daily tasks. Educational level is usually measured in terms of years of education completed and diplomas, certificates, or degrees earned.

Literacy allows readers to acquire health information and navigate health systems. Readers can learn about food preparation and exer- cise programs in newspapers and magazines, comprehend health and safety warnings on consumer products, access air and water quality reports, read posters advertising immunization and screening campaigns, follow directions on medication bottles and hospital discharge orders, understand the health benefits packages offered by employers and the government, apply for aid and benefits, read brochures about their health conditions, use signs to navigate hospitals, and seek out additional infor- mation online or at libraries. People who cannot read will have difficulty with all of these health-related activities. They may delay seeking a diag- nosis or treatment for a health problem because they worry about being unable to complete paperwork at the doctor's office or being ridiculed for not knowing how to read or write. They may have difficulty tak- ing their prescribed medications properly if their healthcare providers have not fully explained dosage and timing and they cannot read the instructions on the label. They may not be able to read the safety infor- mation provided by a pharmacist or know when to return for a follow-up examination.

Female literacy and education are particularly important for family and child health. Women who can read and have at least several years of formal education are able to learn about improved home-health practices and can more easily gain the knowledge and skills they need to reduce their children's risk of malnutrition, illness, and death. 12 Women with more education also tend to report fewer problems accessing health care

4.1 Social Determinants of Health 71

100.----------------------------------.

80+---------------------------------~

60+----

40-\--+',

o India

(2005-2006) Kenya

(2008-2009) Sierra Leone

(2008)

iI No education

!ill Primary school

iI Secondary school or higher

4~4 Percentage of children born at a health facility, by the educational level of the mother.

Source: Data from India: DHS, 2005-06~final report. Calverton MD: International Institute for Population Sciences and Macro International Inc.; 2007 Sep.; and Kenya: DHS, 2008-09--final report. Nairobi and Calverton MD: Kenya National Bureau of Statistics and ICF Macro; 2010 Jun.; and Sierra Leone: DHS, 2008~final report. Freetown and Calverton MD: Statistics Sierra Leone, Ministry of Health and Sanitation, and IeF Macro; 2009 JuI.

than other women do. 4,6 As a result, women with more formal schooling are more likely to give birth at a healthcare facility which means that both mothers and newborns are more likely to survive if there are complications during or after delivery. The children of women with more education are also more likely to receive appropriate preventive and therapeutic medical services 4-6

Unfortunately, even though the economic and health benefits of education are well established, in most world regions fewer girls than boys are enrolled in primary school (elementary school) and secondary school (middle school and high school), and fewer women than men can read. 13 Some health intervention programs focus on helping girls to enroll in primary school and complete their basic education, which is usually con- sidered to be about seven years of classroom learning. Other health-related education programs focus on female adult literacy and sponsor reading classes for mothers and other adult women. General education has health benefits for women and their families and communities.

72 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

100,-----------------------------------~

80 -i--------

60+----{

o India

(2005-2006) Kenya

(2008-2009) Sierra Leone

(2008)

ITiili No education

121 Primary school

III Secondary school or higher

4-5 Percentage of children less than 5 years old who have been vaccinated against measles, by the educational level of the mother.

Source: Data from India: DHS, 2005-06-final report. Calverton MD: International Institute for Population Sciences and Macro International Inc.; 2007 Sep.; and Kenya: DHS, 2008-09-final report. Nairobi and Calverton MD: Kenya National Bureau of Statistics and ICF Macro; 2010 Jun.; and Sierra Leone: DHS, 2OG8-final report. Freetown and Calverton MD: Statistics Sierra Leone, Ministry of Health and Sanitation, and ICF Macro; 2009 Jul.

Just as the health status of individuals and families is related to their socioeconomic position, the health status of communities and nations is linked to their economic status. High-income countries have different health profiles than low-income countries, with higher-income countries typically having lower fertility rates, lower mortality rates, longer life expectancies, a higher proportion of deaths and disability from noncommunicable diseases (NCDs), and a lower proportion of deaths from infectious diseases.

Health economists use a variety of macroeconomic indicators to mea- sure the amount of economic activity in a country. The GDP, GNI, and GNP are three of the most common measures. To make the distinction between these measures clear, consider the way the GDP, GNI, and GNP of Canada would be calculated. The gross dOlnesti!;,: is the total amount of goods and services produced in Canada by both Canadian corporations and foreign corporations. It includes consumer spending,

4.2 Socioeconomic Indicators 73

investment, government spending, and exports. The gms§ income is similar to the GDP, but puts the focus on the total income from the

selling of goods and services produced in the country. The gross 'oM,",",'""""", is the total amount of goods and services produced by

Canadian companies in Canada and by Canadian corporations working in other countries.

Because the amount of goods and services that can be purchased with a given amount of money varies from place to place, these values are often recorded in terms of purchasing power (PPP), which measures how many goods, services, and other products can be purchased in each country with a fixed amount of money (like $1000 U.S. dollars). A popular example of PPP is the "Big Mac Index" that determines the relative price of a McDonald's burger in two different countries and uses that exchange rate to determine the relative value of other items. 14 If a Big Mac costs $2 in one country and $3.50 in another, it is likely that the costs of living are much higher in the $3.50-per-hamburger country, and workers in the higher-priced country will have to earn a much higher salary to stay above the local poverty line than workers in the $2-per-burger country.

GDP, GNI, and GNP can also be recorded in per capita (per person) tenns by dividing the total monetary value by the population ofthe country. The GNI per capita of a country is about equal to the average income of an individual. Although these numbers are only a rough guide to the economic profile of a country, they do allow for comparisons between countries.

4~.(() shows where the richest and poorest countries are located. High-income countries generally have high life expectancies and low- income countries generally have low life expectancies 15.16

Summary values like the GDP and GNI have some major limitations if they are being used to estimate health and development. They do not count unpaid labor like work caring for children and growing food to feed a family. They ignore issues of sustainability, environmental damage, and the distribution of wealth and quality of life (standard of living) in a country. These values show the economic experience of the "average" person living in each country, but the "average" economic measure may be misleading if most people in a given country are very poor and some are extremely rich and there is almost no middle class. Even when a large proportion of the population experiences something near the average reported for the country, there will still be variability in the experiences of individuals. There are millionaires in every country, even the countries with the poorest "average" person. And there are people in every country, even the wealthiest ones, who live on almost nothing.

..... "

o No data <$2000

$2000-9999

4-6 Gross national income (GNI) per capita in 2011 (or the most recent year with data).

Source: Data from World development indicators database. Washington DC: World Bank.

, , ..

~'1,

-.J ~

n ;:c 0> PD Fj I'll ;,>J

"~~

Cfl 0 (j

""' 0 I:I"J (j 0 Z 0 s::: ""' (j V I:I"J Fj I:I"J :;0

s::: ..... z ;.- z Fj CIl

0 'Tl

::r= I:I"J ;.- r< Fj

::r:

.I:: t:: iii 60 1ii >- 0 !:: .l!!

40 0 @ n. x

11.1 ,(l! :::i 20

0 0 10,000 20,000

4.2 Socioeconomic Indicators 75

30,000

GDP per capita

40,000 50,000 60,000

4·-7 Gross domestic product (GDP) and life expectancy in 2010.

Source: Data from Human development report 2010. New York: UNDP; 2010.

The Index is a measure of the inequality in the distribution of incomes within a particular country. A country in which everyone has exactly the same income has an index of 0 (perfect equality) and a country in which one person has all the income and everyone else has zero income has an index of 100 (perfect inequality). For example, Namibia has a Gini Index of 74.3 and a very unequal distribution of income, 16 with the richest 10% of the population making about 107 times more than the poorest 10%.17 In contrast, Denmark has a Gini Index of 24.7 and a relatively equal income distribution, with the richest 10% making 8 times more than the poorest 10%. The United States has a Gini Index of 40.8, and the richest 10% make about 16 times more than the poorest 10%. In general, European countries have the greatest income equality and countries in Africa and the Americas have the greatest income inequalities. Income inequalities are associated with higher mortality rates, especially among younger adults. 18,19

Some measures of socioeconomic status combine economic data with other markers of development, including health status. For example, the Hum~n Ind.ex (RD!), developed by the World Bank, is an estimate of national development based on composite data on longevity (life expectancy at birth), knowledge (school enrollment and adult literacy rate), and income (GDP per capita in purchasing power parity dollars). Some of these measures are highlighted in 4~"2. There is a connection between

--.j 0\

Tab!{> e:l-2 Socioeconomic indicators by country in 20110 n ~ >

South '"0 o-J Country USA Korea Poland Brazil China India Kenya Sierra Leone tTl iAJ

GOP per capita ($) (2009) 45,989 27,100 18,905 10,367 6828 3296 1573 808 ,~

GNI per capita (PPP$) 43,017 28,230 17,451 10,162 7476 3468 1492 737 CIl 0 (J

"" Mean years of schooling 12A 1106 1000 702 705 4A 700 209

(for ages 2::25) t"Ii (J 0

HOI value 00910 00897 00813 0.118 00687 0.547 00509 00336 Z 0

Inequality-adjusted HOI 00771 0]49 0.734 00519 00534 00392 00338 00196 ;s: >-< (J

Quintile income ratio, richest 20% 805 4.1 506 1706 8A 506 1103 801

U to poorest 20% (2000-2011)

trJ o-J trJ

Gini Index for income (2000-2011) 4008 3106 3402 5309 4105 3608 47.1 4205 iAJ ;s: M

Overall life satisfaction (on a scale Z > from 0 to 10, with 10 representing 702 601 508 6.8 407 500 403 401 Z high satisfaction)

o-J [JJ

0 'TI

Source: Data from Human development report 20110 New York: UNDP; 20110 ::r: t"Ii >- r o-J ::ri

4.3 Health of Vulnerable Populations 77

these indicators and health status, with more economically developed coun- tries experiencing a high burden from NCDs and less developed countries continuing to have a high burden from infectious diseases even as NCDs are a growing concern.

4.3 HEAI:I'n OF' VULNERABLE POPULATIONS

Access to health care and other services is associated with wealth, employment, and education, but it is also related to power. Power can be conferred by political position and socioeconomic position. Government officials may have the authority to demand certain services, and business leaders may have the money and connections to access care that is denied to others. Power can also be conferred by cultural systems. A tribal or religious leader may have the power to mobilize people and resources at will. A husband may have power to control his wife's movements and activities.

Powerful people can choose to limit or grant access to goods and resources like property, technology, social networks, and health care. In many popu- lations, some people have the power to secure health for themselves and their families while others without power have limited or no access to the resources they need to be safe and healthy. Members of potentially vulnerable groups-such as ethnic, racial, religious, and tribal minorities; immigrants, refugees, and internally displaced people; prisoners; people with mental illnesses or physical impairments; and older persons-may not have the power to demand access to an equitable level of healthcare. The resulting in health, differences in health experience and health status, exist at many levels. These differences are largely a function of social, political, and economic environments, and not innate biological differences. Some ofthese differences are avoidable, unfair, and unjust, and

.. d 0 °to 20 are reierre to as meqtu u,s.

=<~'.RP.H"'H·.; is based on many dimensions of cultural heritage, tribal affili- ation, nationality, race, religion, and language. R;'!ce refers to superficial categories that group individuals based primarily on physical attributes like skin color. Significant cultural and genetic diversity is present within most

78 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

"racial" groups. For example, in the United States government surveys include only five racial categories: American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White. 21 The "White" category includes most people whose ancestors were Europeans, North Africans, Middle Easterners, or Latin Americans; the "Asian" category includes people with ancestors from countries as diverse as China, India, the Philippines, and Thailand. (These surveys also include only one measure of "ethnicity": whether a person self-identifies as having "Hispanic or Latino" origin.)

Significant differences in health status often exist between different racial and ethnic groups. An assortment of explanations each partly explains the reasons for these health disparities. 22 Racial and ethnic categories may capture some genetic differences between population groups, and genes may predispose people to particular diseases and conditions. For example, Tay-Sachs disease, a fatal neurological disease of young children, is mostly found among people whose ancestors were Jews from Eastern Europe, and sickle cell anemia, also a genetic disorder, is more common in people of African and Mediterranean heritage. Race and ethnicity may also be markers for health behaviors. If members of a particular ethnic group tend to have the same dietary preferences and favorite foods, alcohol and tobacco use habits, and physical activity routines, these practices may account for some of the health differences observed between populations. Race and ethnicity may also be associated with socioeconomic position. Members of marginalized population groups may have lower socioeco- nomic status than other people in their town or city, and poverty is known to be associated with reduced health status. Additionally, discrimination on the basis of race or ethnicity may cause chronic psychosocial stress that leads to poor health outcomes.

Celebrations of the various cultural traditions that exist within a nation or community can bring people with diverse backgrounds together. However, race and ethnicity can also be used to divide people. At worst, these divi- sions can lead to abuse, violence, hate crimes, war, and genocide. On a day-to-day basis, people who belong to minority racial, ethnic, tribal, or reli- gious groups may encounter discrimination along with language, cultural, and belief barriers. These obstacles may exist in the workplace and market- place, and also within the healthcare system. Medical practitioners may be unfamiliar with the special health needs of patients from other backgrounds (in part because many population groups remain understudied by health researchers), and patients may be uncomfortable discussing health con- cerns and being examined by a doctor who is not a member of their group.

4.3 Health of Vulnerable Populations 79

For example, women from traditional cultural and religious sects may be uncomfortable being examined by a male doctor. And in some cases barri- ers to healthcare access are legally sanctioned, such as when proof of legal residency is required before health care can be offered. Because of these obstacles to accessing health care, the health status of minority populations tends to be worse than that of the majority populations.

Indigenous populations tend to have especially low health status com- pared to other residents of their countries. More than 350 million people worldwide are members of indigenous population groups that have main- tained unique cultural traditions (and often also languages) for many gen- erations after the colonization or domination of their traditional homeland by another group. These populations include the Cherokee (and many other groups) of the United States, the Sami of Scandinavia, the Torres Strait Islanders of Australia, the Tangata Whenua (Maori) of New Zealand, the Quichua of Ecuador, the Maasai of Kenya, and the Hmong of Southeast Asia?3 Members of indigenous people groups are more likely to be poor than their nonindigenous neighbors, and usually have higher rates of mor- bidity and premature mortality. 24

4.3JJ:

People move from one community or country to another for a variety of reasons. Some move voluntarily to be closer to family, to start a new job, or to pursue educational opportunities, while others are forced to move because of violence, persecution, or natural disasters. Some migrants intend to settle permanently in their new host country, while others are temporary guest workers. Some immigrants may experience an increase in access to health care when they move from a country with a poor health infrastructure to a country with an easily accessible healthcare system, but many immigrants experience reduced access to health care in their new communities. Thus, it is impossible to speak generically about the health f cc f· . 25 e ~ects 0 mlgratlOn.

However, many migrants do face heightened health risks during their journeys and as they settle in to their new places of residence. 26 For example, smuggled migrants, victims of trafficking, asylum seekers, and refugees may experience violence and deprivation as well as other traumas during their travels. And after arriving, many voluntary and involuntary migrants face obstacles to accessing health care and staying healthy because of poverty, language barriers, and risky jobs.

80 CHAPTER 4 SOCIOECONOMIC DETER.MINANTS OF HEALTH

On any given day, nearly 10 million people across the globe are incarcer- ated (Figure 27 (That 10 million includes more than 2 million adults in the United States, the country with the highest proportion of incarcerated people in the world?7) Prisons, jails, and detention centers house convicted criminals and may also accommodate suspects waiting for trial, juvenile offenders, and illegal immigrants. Many people entering prison already have health problems related to mental illness, drug abuse, malnutrition, and poverty. Severe overcrowding, poor ventilation, poor nutrition, unhy- gienic conditions, lack of access to medical care, abuse by guards, and prisoner-on-prisoner violence, including beatings and sexual assault, may all facilitate the spread of disease within prisons. However, contracting potentially life-threatening infections is not part of any prisoner's sentence, and it is considered unjust not to provide incarcerated people with medi- cal and dental care, adequate nutrition, protection from infectious diseases, and safe conditions. 28 Prisoners are entitled to all fundamental human rights, and need to be protected from medical neglect, starvation, abuse, forced medical experimentation, and other civil rights violations.

800,---------------------------------------------------~

700

600

500

400

300

200

100

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

4-8 Number of prisoners per 100,000 people in the national population in 2008.

Source: Data from Walmsley R. World prison population list, 8th edition. London: International Centre for Prison Studies; 2008.

4.3 Health a/Vulnerable Populations 81

Tuberculosis (TB) is one of the diseases that has become a major health crisis in prisons, especially in the former Soviet Union and in parts of the world with relatively high TB rates in the general population?9 Tuberculosis spreads easily in crowded prison blocks, and late diagnosis and inadequate treatment may allow prisoners with TB to have a contagious form of the disease for lengthy periods of time. The prevalence of TB prisons in some places has been reported to be up to 100 times higher than in the general population (Figure 4_9).29 Over time, an increase in TB in pris- ons will increase the amount of TB in the general population too, because once persons infected with TB are released from prison they may spread TB to their family and friends. Furthermore, each prisoner may become infected with several different strains of TB, contributing to the emergence of multidrug-resistant TB (MDR-TB) strains that are not able to be cured by the standard antibiotics used to treat TB. To prevent further increases in the prevalence of TB in prisons, it is important for every case of TB in prisoners to be detected early and treated consistently with no interruptions in antibiotic therapy.

fIl m ::J "tl .:;: '6 .5 (;) 0 0 6 0

W c. .[l! It! a:

7000

6000

5000

4000

3000

2000

1000

0 Russia Brazil Thailand USA

Iii Country as a whole

!ill! Prisoners

4~9 Tuberculosis in prisoners compared to the general population.

Source: Data from Dara M, Grzemska M, Kimerling ME, Reyes H, Zagorskiy A. Guidelines for control of tuberculosis in prisons. Washington DC: USAID and Tuberculosis Coalition for Technical Assistance; 2009.

82 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

tt4 C1J[,TlIJRE AND HEALTH

is a way of living, believing, behaving, communicating, and understanding the world that is shared by members of a social unit Culture includes a group's norms, values, morals, rules, and customs. Culture also often defines the foods people eat, the clothes they wear, the language they use, the ways they interact with those inside and outside the cultural group, and how they describe and experience illness (feeling unhealthy) and sickness (how a person with poor physical or mental health relates to and is regarded by the community).30 Thus, people with a shared culture may engage in similar health-related behaviors, have similar health beliefs, and have similar preferences about when and where to seek health care.

Different cultures may have distinct explanations about what causes dis- ease. A mechanistic approach sees disease as a dysfunction or breakdown of the human body, which is supposed to function like a well-oiled machine. A moralistic perspective considers health to be the result of clean living and disease to be a type of punishment for wrongdoing. A supernatural viewpoint blames illness on demonic possession, evil eye, or the anger of God or the gods or ancestors. A disequilibrium approach considers disease to be caused by imbalance within the body, such as an imbalance between hot and cold, yin and yang, or the four humors of blood, phlegm, yellow bile, and black bile. Disease may also be attributed to energy or qi imbal- ances; to emotions like fright or grief or jealously; or to stress, weather, food, genus, sex, genes, or age.

These beliefs about health and illness may influence the way people interpret symptoms and diagnoses, the timeline for seeking treatment, and the type of therapy that will be effective. Those with a mechanistic view- point may prefer to be treated by an allopathic practitioner like a physician or a nurse; those with a spiritual perspective may visit a religious advisor; those who see illness as the result of disequilibrium may seek the services of an acupuncturist, a chiropractor, or a massage therapist.

A growing number of people around the world now blend Western medicine and traditional medicine (TM), mixing prescription medica- tions with herbal remedies, manual techniques, and spiritual therapies.

medicine refers to the use of health- care practices outside of a person's own tradition or that are not part of con- ventional medical practice. The distinction between TM/CAM and Western medicine is blurring. Many pharmaceutical formulations are made from plants first used in traditional treatments, and CAM therapies are increas- ingly being integrated into allopathic medical practice. In some countries,

References 83

allopathic and traditional practitioners work alongside one another in the healthcare system so that patients can receive both conventional and com- plementary care?1,32

Culture plays a role in how health and disease are experienced across the lifespan, everything from the way childbirth is approached to decisions about end-of-life care, An understanding of the global diversity of perspec- tives on health, disease, illness, sickness, medicine, and healing is necessary for those working in medicine and in the global public health arena. Public health initiatives and medical interventions must be culturally acceptable as well as socioeconomically affordable and accessible.

1. Describe yourself using the PROGRESS-Plus list of the social determi- nants of health shown in Table 4-1. How do these characteristics affect your health status?

2. How would you survive if you earned only 25 per day? 3. If you had a very small income and limited wealth, how would you

prioritize spending on food, housing, utilities, clothing, education, health care, and entertainment?

4. What are some of the conditions related to poverty that increase the risk of infectious diseases? Noncommunicable diseases (NCDs)? Neuropsychiatric disorders? Injuries?

5. What health disparities are present within your own community? 6. Do you identify with a particular ethnic group? Do you know of any

health conditions that you are at special risk for because of your ethnic background? Are these conditions genetic? Are they related to health behaviors?

7. How do your beliefs about the causes of disease influence your approach to health, well-being, and healing?

8, What complementary and alternative medical (CAM) therapies have you tried? Do you use CAM to complement or replace conventional medical treatment?

1, Kavanagh J, Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus. Equity Update. 2008;2:1-3.

2. Wilkinson R, Marmot M. Social determinants of health: the solid facts. Copenhagen: WHO; 2003.

84 CHAPTER 4 SOCIOECONOMIC DETERMINANTS OF HEALTH

3. Human development report 2011. New York: UNDP; 2011. 4. India: DHS, 2005-06---final report. Calverton MD: International Institute for Population

Sciences and Macro International Inc.; 2007. 5. Kenya: DHS, 2008-09-final report. Nairobi and Calverton MD: Kenya National

Bureau of Statistics and ICF Macro; 2010. 6. Sierra Leone: DHS, 2008-final report. Freetown and Calverton MD: Statistics Sierra

Leone, Ministry of Health and Sanitation, and ICF Macro; 2009. 7. Geyer S, Peter R. Occupational status and all-cause mortality: a study with health insur-

ance data from N ordrhein-Westfalen, Germany. Eur J Public Health. 1999;9: 114-118. 8. Kunst AE, Groenhof F, Mackenbach JP; EU Working Group on Socioeconomic

Inequalities in Health. Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies. BMJ. 1998;316: 1636-1642.

9. Jin RL, Shah CP, Svoboda TJ. The impact of unemployment on health: a review of the evidence. CMAJ. 1995;153:529-540.

10. Paul KI, Moser K. Unemployment impairs mental health: meta-analysis. J Vocational Behav. 2009;74:264-282.

11. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: a system- atic review and meta-analysis of unemployment and all-cause mortality. Soc Sci Med. 2011;72:840---854.

12. King EH, Hill MA. Women's education in developing countries: barriers, benefits, and policies. Baltimore MD: Johns Hopkins University Press; 1993.

13. State of the world's children 2012. New York: UNICEF; 2012. 14. Ong LL. Burgernomics: the economics of the Big Mac standard. J Int Money Finance.

1997;16:865-878. 15. World development indicators database. Washington DC: World Bank. 16. Human development report 2010. New York: UNDP; 2010. 17. Human development report 2009. New York: UNDP; 2009. 18. Dorling D, Mitchell R, Pearce J. The global impact of income inequality on health by

age: an observational study. BMJ. 2007;335:873. 19. Wilkinson RG, Pickett KE. Income inequality and population health: a review and

explanation of the evidence. Soc Sci Med. 2006;62: 1768-1784. 20. Gwatkin DR. Health inequalities and the health of the poor: What do we know? What

can we do? Bull World Health Organ. 2000;78:3-18. 21. Revisions to the standards for the classification offederal data on race and ethnicity.

Washington DC: Office of Management and Budget COMB); 1997. 22. Dressler WW, Oths KS, Gravlee CC. Race and ethnicity in public health research:

models to explain health disparities. Ann Rev Anthropol. 2005;34:231-252. 23. Bartlett JG, Madariaga-Vignudo L, O'Neil JD, Kuhnlein HV. Identifying indigenous

peoples for health research in a global context: a review of perspectives and challenges. lnt J Circumpolar Health. 2007;66:287-307.

24. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374:65-75.

25. International migration, health & human rights. Geneva: WHO; 2003. 26. Gushulak BD, MacPherson DW. The basic principles of migration health: population

mobility and gaps in disease prevalence. Emerg Themes Epidemiol. 2006;3:3.

References 85

27. Walmsley R. World prison population list, 8th edition. London: International Centre for Prison Studies; 2008.

28. Standard minimum rules for the treatment of prisoners. Geneva: Office of the United Nations High Commissioner for Human Rights; 1977.

29. Dara M, Grzemska M, Kimerling ME, Reyes H, Zagorskiy A. Guidelines for control of tuberculosis in prisons. Washington DC: USAID and Tuberculosis Coalition for Technical Assistance; 2009.

30. Boyd KM. Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts. Med Humanities. 2000;26:9-17.

31. Legal status of traditional medicine and complementary/alternative medicine: a world- wide review. Geneva: WHO; 200l.

32. Traditional medicine strategy 2002-2005 (WHO/EDMITRM/2002.1). Geneva: WHO; 2002.

5.1 INEQUAIJ'IIES IN CHILD DEKfH

In 2010, about 8 million children died. 1 About half of these deaths happened in sub-Saharan Africa and about one-third in South Asia. Less than 1 % occurred in high-income countries. About 1 in 5 newborns in central Africa and 1 in 13 newborns in South Asia do not survive to their fifth birthdays.2 In contrast, about 1 in 167 newborns in North America and 1 in 270 newborns in Western Europe die during their first five years. Thus, although the child mortality rate is decreasing in nearly every region of the world 5-1), significant gaps remain (FIgure 5·_2).1,3

Most of the children who die this year will be in their first five years of Hfe, the age group professionals working in the field of maternal and heaUh (often shortened to just "MCH") call " About one-third of under- 5 deaths occur in neonates (newborns in their first 28 days after birth), about one-third in infants 29 days through 1 year old, and about one-third in children between their first and fifth birthdays. T~.ble 5-1 sum- marizes the leading causes of under-5 death: neonatal conditions, diarrhea, pneumonia, malaria, other infections, injuries, and undernutrition. 4

Figure 5-3 shows the distribution of causes of death for under-5s who survived for at least one month after birth (to the postneonatal period).4 The vast majority of these pediatric deaths are due to preventable or treatable conditions like diarrhea, pneumonia, malaria, measles, and other infections (such as HlV/AIDS, meningitis, and pertussis). If malnutrition, which contributes to at least one-third of child deaths,S is also considered, then

88 CHAPTER 5 CHILD HEALTH

400,-------------------------------------------,

300+---------------------------------------1-=--~

200+---------------------------__ ----------

100+---------------~-----------

USA South Poland Brazil China India Kenya Sierra Korea Leone

1111970 1111980 01990 1112000 1112010

Figure 5-1 Probability of dying during the first five years of life per 100,000 live births between 1970 and 2010.

Source: Data from Rajaratnam JK, Marcus JR, Flaxman AD, et al. Neonatal, postneona- tal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress toward Millennium Development Goal 4. Lancet. 2010;375:1988-2008.

the proportion of preventable deaths is even higher. The majority of child deaths can be prevented with simple, low-cost interventions that have been proven to be effective. The following sections provide an overview of each of the most common causes of child death and the interventions for each condition that already save thousands of lives each year and could save thousands more if they were implemented more widely.

5.2 NEONATAL MORTALITY

Most deaths of newborns occur because the babies are born too early and are underdeveloped, because of complications during labor and deliv- ery that may result in asphyxia or birth trauma that damages the brain or other organs (complications that are common when women do not have access to a healthcare professional when giving birth), and because of infections acquired around the time of birth. 6 About 3.5 million neonates die each year (Table 5_2),4 with most deaths occurring in low-income countries (Figure 5_4).7 (That number includes only live births; it does not include the approximately 3 million stillbirths that occur each year. 6)

D No data <10

10-24.99

25-99.999

2: 100

5~2 Child mortality during the first five years oflife per 1000 live births in 2010.

Source: Data from World development indicators database. Washington DC: World Bank.

~ tv

~ \:)

~ ~ -.

~ ~ ~.

00 \0

90 CHAPTER 5 CHILD HEALTH

Tabie ~"! Causes of mortality in children during their first five years of life. Undernutrition is not listed separately but is a contributing factor to about one-third of these deaths.

Cause

Neonatal deaths, including preterm birth complications, birth asphyxia, sepsis, and other conditions

Diarrheal diseases

Acute respiratory infections (ARls)

Malaria

Injuries

HIV/AIDS

Measles

Other infections

All other causes

Estimated Number of Deaths Worldwide in 2008

3,600,000

1,300,000

1,200,000

750,000

300,000

200,000

100,000

1,100,000

350,000

Estimated % of All Pediatric Deaths

41%

14%

13%

Note: These are estimates based on prediction models, rather than actual counts, because reporting systems in most countries are incomplete. Other research groups report slightly different estimates.

Source: Data from Black RE, Cousens S, Johnson HL, et aL; Child Health Epidemiology Research Group (CHERG) of WHO and UNICEF. Global, regional, and national causes oI child mortality in 2008: a systematic analysis. Lancet. 2010;375:1969-1987.

The implementation of several proven interventions before birth, dur- ing delivery, and in the minutes, hours, and days after birth significantly improves the likelihood of survival of newborns 8

53 DIARRHEA

is an increase in the volume of stool and the frequency of defecation, and it can quickly cause dehydration and death in young children. Diarrhea causes the loss of excessive amounts of water and

21%

Measles 2%

Injuries 5%

All other causes 7%

Malaria 14%

5.3 Diarrhea 91

24%

Acute respiratory infections (ARls)

23%

5-3 Causes of death in children ages 29 days through 5 years old.

Source: Data from Black RE, Cousens S, Johnson HL, et a1.; Child Health Epidemiology Research Group (CHERG) of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375: 1969-1987.

the loss of electrolytes like sodium, potassium, and bicarbonate. Severe dehydration can cause low blood pressure (because fluid loss decreases blood volume), a fast and weak pulse, rapid breathing (but insufficient oxygen intake), sunken dry eyes, loss of skin elasticity, muscle contrac- tions and convulsions, and delirium. Electrolyte imbalances can lead to Iddney and heart failure, and eventually to death.

Diarrhea is usually caused by an infection like rotavirus (which is vaccine-preventable) or bacteria such as E. coli, Shigella, Campylobacter, or Salmonella. (It can also be caused by conditions like lactose intolerance that cause poor absorption of water, and by food allergies, some antibiotics and other medications, and some chemicals, such as caffeine and toxins.) The infectious agents that cause diarrhea are transmitted through con- taminated food and water, by physical contact with people who have an infection that causes diarrhea, and by contact with feces. Together, unsafe drinking water, inadequate availability of water for hygiene, and lack of access to sanitation (such as a toilet or latrine) are estimated to contribute to about 90% of deaths from diarrhea each year. 9 Prevention of diarrhea

92 CHAPTER 5 CHILD HEALTH

Table 5«·2 Causes of neonatal mortality.

Estimated Number of Neonatal Deaths Estimated % of All

Cause Worldwide in 2008 Neonatal Deaths

Preterm birth complications 1,000,000 29%

Birth asphyxia 800,000 23%

Sepsis 500,000 15%

Pneumonia 400,000 11%

Congenital abnormalities 300,000 8%

Diarrhea 80,000 2%

Tetanus 60,000 2%

Other 400,000 11 %

Source: Data from Black RE, Cousens S, Johnson HL, et al.; Child Health Epidemiology Research Group (CHERG) of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375:1969-1987.

50.-------------------------------------------------,

40+---------------------------------------------

30+----------------------------------

20~---------------------------------

10~--------------------

USA South Poland Brazil China India Kenya Sierra Korea Leone

5-4 Neonatal mortality rate (death during the first 28 days after birth) per 100,000 live births in 2010.

Source: Data from State of the world's children 2012. New York: UNICEF; 2012.

5.3 Diarrhea 93

Table ~3 Examples of effective interventions for neonatal health.

Time

Preconception

Antenatal/ prenatal (before birth)

Intranatal/ intraparturm (during delivery)

Postnatal (after birth)

Intervention

" Folic acid supplementation to prevent neural tube defects

" Birth spacing

" Tetanus toxoid immunization

.. Syphilis screening and treatment

<> Intermittent preventive treatment in pregnancy (IPTp) of malaria (in endemic areas)

<0 Maternal supplementation with iron, iodine, zinc, and calcium

.. Maternal anti helminthic (deworming) treatment

" Prevention of mother-to-child HIV transmission

" Clean delivery

.. Detection and management of breech births (by Caesarian section, if required)

" Antibiotics for preterm premature rupture of membranes

.. Corticosteroids for preterm labor

" Early diagnosis of complications during labor

" Newborn resuscitation

" Delayed umbilical cord clamping

'" Breastfeeding

" Kangaroo mother care (keeping low birthweight babies in an upright position on a parent's bare chest so they have skin-to-skin contact and the baby's ear is near the parent's heart)

., Prevention and management of hypothermia

.. Nevirapine and replacement feeding for babies born to mothers with HIV infection

" Pneumonia case management

., Neonatal vitamin A supplementation

" Insecticide-treated bed nets for malaria prevention

Source: Information from Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, Bernis L; Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005;365:977-985.

94 CHAPTER 5 CHILD HEALTH

requires access to clean water for drinking, food preparation, handwashing, and bathing, and the safe disposal of feces 0

About 205 billion cases of diarrhea occur in under -5 children each year, 10 and more than 1 million children die from diarrhea each year. 11 Once a child has diarrhea, the most important method for preventing death is the administration of oral Sometimes called oral rehydration solution or salts (ORS), ORT is a solution of sugar, salt, and clean drinking water that replaces lost fluids and restores the balance of electrolytes in the bloodo Oral rehydration salts are sometimes distributed in packets at clinics, usually in a relatively new "low osmolarity" formulao Parents can also make their own ORS solution by mixing 8 teaspoons of sugar and one half teaspoon of salt into one liter of boiled water. Potassium can be added to the solution through fmit juice, coconut water, or mashed bananas 0 Children with diarrhea need to drink ORT every time they pass watery stool for a total of at least one liter each dayo If they also have vomiting they need to drink more ORT in order to replace those lost fluidso Zinc supplementation also helps prevent diarrhea deaths 0 12

Adequate nutrition is also important because malnutrition increases the risk of death from diarrheao Children with diarrhea should be encouraged to eat the same foods that they normally consume (as long as they are not vomiting too much to keep food down), and breastfed children should continue to breastfeed during their illnesso After children recover from diarrhea they should be encouraged to eat more food than normal to regain lost weight and lost nutrientso

ORT combined with cO!:1ltinued leads to the best health outcomes for children with diarrhea, but in developing countries fewer than half of children with diarrhea receive this coIe0 7 Additional health education for parents and communities is needed in order to increase the use of ORT, to promote continued feeding for sick children, and to facilitate water and sanitation development and other actions that prevent diarrhea

The main function of the body's respiratory system is the exchange of gases, which mostly means taking in oxygen and getting rid of carbon dioxide When a person takes a breath, the air enters the lungs and fills little air sacs called alveoli, Each alveolus is wrapped in tiny blood vessels called capillaries and has a very thin surface so that gas exchange

5.4 Pneumonia 95

TFlbie 5-4 Key methods for preventing and treating diarrhea.

Prevention (primary prevention to reduce new infections)

.. Rotavirus and measles immunization

" Early and exclusive breastfeeding of infants, followed by complementary feeding

" Vitamin A supplementation

.. Hand washing with soap

.. Improved water supply quantity and quality

.. Community-wide sanitation (safe disposal of stool, latrine use instead of open defecation)

Treatment (secondary prevention to reduce disease severity and death once a child is ill)

" Fluid replacement to prevent dehydration

o Oral rehydration therapy (ORT)

o Breastfeeding

o Continued feeding during illness

.. Zinc supplementation

Information from Diarrhoea: why children are dying and what can be done. New York/Geneva: WHO/UNICEF; 2009.

5-0 5 Path of blood through the heart, lungs, and body.

can take place. When a person inhales, oxygen is absorbed into the blood in those capillaries. This oxygenated blood is pumped into the heart and then to the rest of the body so that all of the cells can receive the oxygen they need to function properly. When the cells take in oxygen from nearby capillaries, they can also get rid of carbon dioxide and other waste prod- ucts by dumping them into the blood. Carbon dioxide and other waste

96 CHAPTER 5 CHILD HEALTH

products can then be released from the blood into the alveoli. When a person exhales, these wastes are expelled from the body.

Pneumonia occurs when part of a lung fills with fluid. If the alveoli are filled with fluid, they cannot efficiently exchange oxygen and carbon dioxide. The symptoms of an acute respiratory illness (ARI) of the lower respiratory tract usually include a cough accompanied by difficult rapid breathing. People with pneumonia can feel like they are drowning as fluid fills their lungs and they develop hypoxia (lack of oxygen). A child with severe infection may even turn bluish in color due to hypoxia.

Approximately 150 million cases of pneumonia occur in under-5 children worldwide each year.13 Acute lower respiratory infections can be caused by a variety of pathogens, but most often are caused by bacteria. The most common bacterial causes of pneumonia are pneumococcus (Streptococcus pneumoniae) and Haemophilus injluenzae type b (Rib). Both of these infec- tions are vaccine-preventable. Other common agents include Staphylococcus aureus and Klebsiella pneumoniae. 13

Bacterial infections can often be cured by inexpensive oral antibiotics if treatment is sought soon after the onset of symptoms. However, only about 60% of the world's children with suspected pneumonia are taken to a healthcare provider and only about one-third are treated with antibiotics.? Thus, one component of improving child survival is educating caregivers about the importance of seeking medical care as soon as the symptoms of pneumonia appear, so that a course of antibiotics can be started. (Antibiotics will not speed recovery from colds and other upper respiratory infections like bronchitis that are usually caused by viruses, but they are usually effec- tive against early-stage bacterial pneumonia.)

5.5 MALARIA

Malaria is a parasitic infection spread by the bites of infected mosquitoes. Malaria usually presents with a fever and flu-like symptoms, but children with malaria can deteriorate quickly and enter into a coma (cerebral malaria). In many cases, children with malaria can be successfully treated with inexpensive antimalarial tablets, but malaria can cause weeks or even months of illness due to relapses and severe anemia (too few red blood cells). Reinfection with malaria is common, and in many tropical areas the average child may have several bouts of malaria each year. Furthermore, babies born to women with malaria have an increased risk of low birth weight, birth com- plications, and stillbirths. One of the most effective ways to prevent infection

5.7 Undernutrition and Breastfeeding 97

is the use of insecticide-treated bednets (ITNs) that shield sleeping people from the bites of mosquitoes, yet many households in regions where malaria is common do not have ITNs or fail to use them consistently.

5.6

Hundreds of thousands of children die each year from vaccine-preventable diseases. Measles remains one of the most common causes of vaccine- preventable mortality, even though the rates of measles mortality have dropped significantly in recent years. 14.l S Measles is a highly contagious viral infection that is spread from one person to another through the air or by contact with secretions from the nose or throat of people with the infection. The common symptoms are a fever, runny nose, cough, and sore eyes, followed by a rash that starts on the face and spreads down the body. But measles may also cause diarrhea, ear infections, pneumo- nia, and encephalitis (brain swelling), and these severe complications can lead to permanent disabilities, especially in children who are under- nourished. There is no treatment available for measles, so prevention through immunization is crucial. Other vaccine-preventable infections that cause many deaths of children each year include Haemophilus influenzae type b (Hib), pneumococcus, and rota virus , among others. Table 5~5lists all childhood vaccinations currently recommended by the World Health Organization (WHO) and by the U.S. Centers for Disease Control and Prevention (CDC).16.17

Undernutrition occurs when children do not consume enough calories or do not take in adequate amounts of specific nutrients like proteins, fats, vitamins, and minerals. In addition to deaths directly caused by under- nutrition, being malnourished increases the risk of death from infectious diseases. Many cases of undernutrition could be prevented a simple set of nutritional interventions that include having infants consume only breast- milk during their first six months of life, continuing to provide breastmilk after introducing solid foods into the infant's diet, and providing vitamin A and zinc supplementation when necessary.s

New mothers should be encouraged to breastfeed their babies so that they can pass both nutrients and disease-fighting antibodies to their children.

98 CHAPTER 5 CHILD HEALTH

Tab~e 5-5 Recommended childhood immunizations. The WHO schedule is for most children worldwide. The CDC schedule is for children in the United States.

Agent Agent Type WHO Schedule CDC Schedule

Chickenpox (varicella) Virus (j;

Cholera Bacterium 0

Diphtheria Bacterium @ III

Hepatitis A virus Virus 0 ®

Hepatitis B virus Virus © @

Haemophilus influenzae Bacterium ~ ®

type b (Hib)

Human papillomavirus Virus .. @ Influenza Virus 0 e

Japanese encephalitis Virus 0

Measles Virus ® OIl

Meningococcal Bacterium 0 III

Mumps Virus 0 'iil

Pertussis (whooping cough) Bacterium ® ®

Pneumococcal Bacterium <II @

Polio (poliovirus) Virus ~ Ei)

Rabies Virus 0

Rotavirus Virus 0 II>

Rubella (German measles) Virus 0 ~

Tetanus Bacterium III @

Tuberculosis Bacterium @

Typhoid Bacterium 0

Yellow fever Virus 0

@ Recommended for all children o Recommended for children in some countries or some high-risk areas and

population groups

Source: Data from Recommended routine immunization: summary of WHO position papers. Geneva: WHO; 2010 Oct 21; and 2011 childhood & adolescent immunization schedules. Atlanta GA: CDC; 201 i .

5.7 Undernutrition and Breastfeeding 99

Breastmilk contains all of the nutrients and water babies need, and it also includes digestive enzymes and antibodies and other immune factors that protect against harmful infections and promote health. For example, bifidus factor encourages the multiplication of helpful bacteria called Lactobacillus bifidus in the baby's intestines. Colostrum, the milk produced in the first days after giving birth, is especially beneficial because it contains large quantities of an antibody called secretory immunoglobulin A (IgA). 18 breastfeeding, breastfeeding within the first hour after giving birth, also increases the neonatal survival rate.

In ideal circumstances, infants should be exclusively breastfed for the first 6 months of life. Exdusive brcastfeeding means that breastmilk is the only substance the baby consumes, and that no supplemental water, juice, cow or goat milk, porridge, rice water, or any other foods are fed to the baby. However, only about one in three children worldwide is exclusively breastfed for the first six months of life.7 This low percentage contributes to illness and death from undernutrition and diarrhea.

After six months of exclusive breastfeeding, complementary roods should be introduced into the infant's diet while continuing breastfeeding for up to 2 years or more (Figure 5_,6).19 "Complementary" means that the foods accompany breastmilk and do not immediately replace it.

Not all women are able to exclusively breastfeed. Some mothers do not produce adequate milk for their babies and have to supplement with formula at an early age, some have HIV infection and do not want to risk passing the virus to their babies through breastmilk, and some have work schedules that do not allow them to feed their babies every few hours. Newborns whose mothers have died in childbirth are also not able to be breastfed by their mothers. Breastmilk substitutes for infants must provide hydration plus all of the essential nutrients. Commercial infant formula is usually the best substitute for breastmilk, because cow's milk, tea, rice water, and other substitutes do not provide all the nutrients of breastmilk or infant formula.

I Birth

I 12 Months

I 18 Months

Figure 5~6 Breastfeeding timeline. Babies should have only breastmilk for the first 6 months of life, and complementary foods should be added as the baby is weaned.

100 CHAPTER 5 CHILD HEALTH

However, using infant formula can be a challenge for mothers and families with a lack of access to clean water, difficulties reading and following the mixing instructions, or limited incomes to pay for commercial products.

Additional concerns about the use of formula in lower-income countries stem from the marketing strategies used by Nestle and other infant formula companies in the 1970s.2o Hospital maternity wards in developing countries were sponsored by formula companies, and new mothers would be sent home with formula samples and no breastfeeding education. New mothers who do not breastfeed quickly lose the ability to produce milk and must then rely on breastmilk substitutes, so providing a limited amount of free formula may create a dependency on the product. Worse, some companies hired "milk nurses" to go into communities in nursing uniforms to adver- tise formula, implying that formula was better than breastmilk. In 1981 the World Health Assembly addressed these problematic marketing practices with their adoption of the International Code of Marketing of Breast-milk Substitutes?1 The Code recognizes that "when mothers do not breastfeed, or only do so partially, there is a legitimate market for infant formula." But it stresses that breastmilk is the best option, and says that new mothers who are given information about the use of infant formula must be informed about the "social and financial implications of its use, the health hazards of inappropriate foods or feeding methods, and, in particular, the health hazards of unnecessary or improper use of infant formula and other breast- milk substitutes.,,21 The Code stipulates that marketing personnel (even if they are healthcare professionals) should not directly contact pregnant women or new mothers, health facilities should not promote formula use, and samples of formula should not be distributed at hospitals or by retailers. Nestle and other major formula producers have adopted the International Code of Marketing of Breast-milk Substitutes and no longer directly market to pregnant women or new mothers in developing countries.

Mothers do need to be provided with the information to make an informed choice about whether to breastfeed and how long to breastfeed. Attitudes toward breastfeeding also need to be addressed, as in many cultures breastfeeding is discouraged. Employers rarely have a private room available for mothers who would like to use a breast pump. Women are not always free to breastfeed in public areas, even the "public" areas of their own homes. And new grandmothers who bottlefed their own babies may discourage their daughters from choosing breastfeeding. It is particularly important to promote breastfeeding as an option for new mothers in places where breastfeeding is not the cultural norm. The phrase "breast is best" needs to be accompanied by conditions that support breastfeeding.

5.8 Global Child Health Initiatives 101

Older infants and young children need access to a variety of nutrient-rich, age-appropriate foods. While most child hunger stems from a lack of food at the household level, it may be possible in some cases to improve the nutritional status of children by changing social eating practices. In cultures where food is traditionally served to men first and to children last, children may not get an adequate amount of high-quality proteins. In cultures where everyone at the meal eats from a common pot, small children may not eat quickly enough to secure adequate calories. New serving practices, such as giving children their own plate or bowl of food, may help children to consume the food they need to be healthier.

Several multinational initiatives have sought to standardize efforts to improve global child health 22,23 One of the first efforts sup- ported primary health care (PHC), a system of community-based health that employs community health workers and focuses as much on prevention as on cures. PHC became the focus of most international health work follow- ing the Alma-Ata Conference of 1978, which developed the goal of "Health for All by 2000" through the reduction of barriers to healthcare access, especially in poor and rural areas. PRC prioritizes prevention of locally common infectious diseases, promotion of nutrition, provision of essential drugs and treatments for common diseases and injuries, coordination of health services with traditional health practitioners, and programming for maternal and child health (including immunization and family planning). PRC is a "horizontal" approach to health care that emphasizes routine

T8bie 5-6 Acronyms for global child health programs.

Acronym Program

PHC Primary Health Care

EPI Expanded Program on Immunization

GOBI Growth monitoring, Oral rehydration therapy, Breastfeeding, and Immunization

GOBI/FFF Growth monitoring, Oral rehydration therapy, Breastfeeding, and Immunization + Family planning, Food production, and Female education

IMCI Integrated Management of Childhood Illness

102 CHAPTER 5 CHILD HEALTH

access to comprehensive primary care, rather than a "vertical" approach that targets selected diseases with specific interventions (like special vaccination days) that are managed outside the public healthcare system.24

A hallmark of PHC is regularly scheduled health clinics for children under 5 years of age that monitor child growth and provide necessary immunizations for children from birth through their fifth birthdays. Because all children, whether sick or healthy, are encouraged to have frequent interactions with the healthcare system through these under-5 health clinics, warning signs for potentially life-threatening conditions in relatively healthy children can be detected early and treated. For example, growth monitoring tracks child weight so that caregivers will know if a child has lost weight or is failing to gain weight. Weight loss or stagnation can be a sign of serious illness, and early detection means that a nutritional interven- tion can be implemented before a health crisis occurs.

The Expanded Program on Immunization (EPI) was started in the mid- 1970s by the World Health Organization and expanded the number and types of vaccines typically given to children. EPI succeeded in significantly increasing the percentage of children receiving essential immunizations.

GOBI, an initiative started in the 1980s by UNICEF, focused on increasing child survival through promotion of four simple interventions: growth monitoring, oral rehydration therapy for diarrhea, breastfeeding, and immunization. Later, a partnership between UNICEF, WHO, and the World Bank added three community-focused components to the mix-ftmily planning, food production, andjemale education--creating a program called GOBIIFFF.

Integrated Management of Childhood Illness (lMCI) is a package of sim- ple, affordable, and effective interventions for major childhood illnesses and undernutrition that was first developed in the 1990s by UNICEF and WHO. 25

The term "integrated" has several layers of meaning. One aspect of integra- tion is the emphasis on the interrelatedness of children's health conditions. A child with malaria is more vulnerable to diarrhea. A child with vitamin A deficiency is more vulnerable to death from measles. Clinicians working under an lMCI framework complete a series of medical assessments on each sick child that allow for diagnosis of underlying conditions in addition to the primary illness. Integration also emphasizes families and communities work- ing together with the staff of various levels of healthcare facilities to care for sick children, and the staff of outpatient clinics knowing when to refer sick children to inpatient hospital departments or specialty clinics.

The aim of IMCI is to improve family and community health practices and to improve case management skills of healthcare staff. To further this goal, IMCI provides home healthcare guidelines for families with young children (Table 5_7)26 and evidence-based decision charts for

5.8 Global Child Health Initiatives 103

Tabie 5~7 Key family practices under IMCI.

Physical and Mental Growth

Disease Prevention

# Practice

Breastfeed infants exclusively for at least six months (if the mother does not have HIV infection)

2 From 6 months of age, feed children good-quality complementary foods while continuing to breastfeed up to two years (or longer)

3 Ensure that children receive adequate amounts of micronutrients (especially vitamin A, iron, and zinc) either in their diet or through supplementation

4 Promote mental and social development by responding to a child's needs for care and by talking, playing, and providing a stimulating environment

5 Dispose of feces safely and wash hands after defecation or contact with children's feces, before preparing meals, and before feeding children

6 Protect children in malaria-endemic areas from mosquito bites by ensuring that they sleep under insecticide-treated bed nets

7 Provide appropriate care for HIV-infected people and those affected by HIV (especially children orphaned by HIV/AIDS), and take action to prevent further HIV infections

Appropriate 8 Home Care

Continue to feed and offer more fluids, including breastmilk, to children when they are sick

9 Give sick children appropriate home treatment for infections (such as ORT for diarrhea and first aid for injuries)

10 Protect children from injuries and accidents, and provide treatment when necessary

11 Prevent child abuse and neglect, and take action when it does occur

12 Involve fathers in the care of their children and in the reproductive health of their families

Care 13 Recognize when sick children need treatment outside the home Seeking and seek care from appropriate providers and 14 Take children to complete a full course of recommended Compliance immunizations before their first birthday

15 Follow the health provider's advice on treatment, follow-up, and referral

16 Ensure that every pregnant woman has adequate antenatal care, and seeks care at the time of delivery and afterward

Source: Information from Child health in the community-- "community fMC!" briefing package for facilitators. Geneva: WHO; 2004.

104 CHAPTER 5 CHILD HEALTH

clinicians to use when assessing children and treating common illnesses. For example, consider the ideal integrated response to a child who has diarrhea. The family of the child should know how to prepare ORT cor- rectly and know what symptoms require the child to be taken to the local clinic or hospital. The clinic should support community health education programs and be prepared to provide care for advanced cases of dehy- dration and to make referrals for hospital-based treatment if necessary. Or perhaps a family is concerned about its children contracting malaria. In an integrated response, the parents would be instructed to install and consistently use ITNs to prevent mosquito bites and to monitor their chil- dren for fevers and other symptoms of malaria. The local clinic should support community health education efforts, be prepared to effectively treat cases of malaria that do occur, and make referrals for advanced treatment if needed.

Each of these global programs had contributed to significant improve- ments in global child health, but infant and child health statistics show that there is still a great deal of work to be done. In order to ensure that as many children as possible have a healthy start in life, it is important to further increase access to essential drugs and immunizations, to educate parents about the use of ORT and ITNs, to promote breastfeeding, to improve access to safe drinking water and nutritional foods, and to implement other important public health measures.

5.9 THE RIGHTS OF CHILDREN

In addition to infectious disease and malnutrition, children may be at risk for injury and abuse. Both boys and girls may be subjected to physical, emo- tional, and sexual abuse by family members or other adults or children. In 1989, the General Assembly of the United Nations adopted the Convention on the Rights of the Child. Several of the articles of the Convention are related to child health and survival. The rights of the child include an adequate standard of living, freedom from all forms of exploitation, protection from all forms of violence, access to education and appropriate information, the right to be heard, and the right to rest, leisure, and play. Acknowledging the right of every child in the world to these basic protections is a start, but this recognition must be acted on to be meaningful. The sad reality is that millions of children are denied these protections.

Many children are sent to work at an early age. Some types of work, such as when rural children work alongside their parents on the family

5.9 The Rights of Children 105

farm, can be a positive experience. But some children develop lasting physical and psychological scars from long hours doing domestic labor, agricultural work, or factory work. The International Labor Organization (ILO) makes a distinction between children participating in economic activity-working (whether for payor not) for a few hours or full time doing activities other than household chores or schooling-and children who are involved in "child labor." It is permissible for children 12 years old and older to spend a few hours a week doing light work that is not hazardous. But it is a child labor violation when a child has an excessive workload, unsafe work conditions, or extreme work intensity, because any of these conditions may harm a child's physical health, mental health, or moral development. At worst, a child may be sold by his or her family into bonded labor, forced into sex work, or forced into armed conflict. The ILO estimates that more than 300 million children between the ages of 5 and 17 were engaged in labor in 2008, of whom about 115 million conducted hazardous work. 27

Girls are especially vulnerable to abuse and neglect. In some parts of the world, they are subject to infanticide, heavy domestic responsibilities at a very early age, female genital mutilation (FGM), violence, and sexual abuse. When a family has limited resources, girls may face discrimination in food allocation, may not be allowed to attend school, and may be forced into early marriage, sometimes even before reaching puberty. In 1995, the United Nations adopted the Beijing Declaration that affirms several strategic objectives for promoting the rights of the "girl-child," including eliminating educational discrimination, the exploitation of child laborers, and violence against children. 28 Although some improvements have been achieved, such as increasing school enrollment, significant inequalities between boys and girls remain in many regions of the world.

Children with special needs are also vulnerable, especially those who require early medical intervention in order to live life to the fullest. Babies with a cleft lip or cleft palate, which is when the upper lip or the roof of the mouth is separated, may require surgery to be able to suck properly and receive adequate nutrition. Children born with cerebral palsy or spina bifida can develop their motor skills to their highest potential only if they have physical therapy and the use of braces, crutches, and walkers at an early age. Language and communication skills are learned best in the early years (until about age 7), so children who are deaf or hearing impaired do best when they start speech and language therapy as early as possible. Children with other sensory impairments, such as blindness, or with devel- opmental disorders also benefit from early therapy that focuses on skills

106 CHAPTER 5 CHILD HEALTH

such as mobility, orientation (the ability to locate oneself in space), and communication. Unfortunately, many parents do not have the resources or ability to have their children start therapy at an early age, do not know what therapy to provide at home for their children, and are not able to help their disabled children access education. 29

Several groups are dedicated to protecting children. The most prominent is UNICEF. UNICEF (initially called the United Nations International Children's Emergency Fund but now shortened to the United Nations Children's Fund) has a mandate to advocate for the protection of children's rights, to help meet their basic needs, and to expand opportunities for children to reach their full potential. UNICEF advocates for children by promoting prenatal health care, girls' education, childhood immunizations and nutrition, HIV/AIDS prevention among young people, and protective environments free of violence, abuse, and exploitation. UNICEF also responds to emergencies in order to protect the rights of children and to relieve the suffering of children and their caregivers. About two-thirds of the UNICEF budget comes from governments, but the rest must be obtained from nongovernmental organizations, partnerships, and private donations. Additionally, a wide variety of other public and private orga- nizations promote child health, nutrition, and education, both locally and internationally.

5.10 DISCUSSION QUESTIONS

1. Do you know any parents who have experienced the death of a child? How did they respond to their loss? How do you think you would react if you had a son or daughter die at a young age?

2. In some regions of the world, more than 1 in 5 children die at a young age. How do you think the loss of so many children impacts families and communities?

3. Do you know any children who have died from pneumonia, diarrhea, malaria, measles, or undernutrition? What does your answer indicate about global health inequalities?

4. What do you notice about the differences between the WHO childhood immunization recommendations and the CDC schedule?

5. If you had an infant, would you plan to breastfeed (or encourage your partner to breastfeed)? Why or why not? Would you feel comfortable breastfeeding (or having your partner breastfeed) outside the privacy of your home?

References 107

6. Have you seen advertisements or public service announcements pro- moting vaccination, nutrition, or other child health practices? What organizations sponsor these ads? What do these ads suggest are key child health issues in your community?

7. What educational and other resources are available for children in your community who have special needs?

1. Rajaratnam JK, Marcus JR, Flaxman AD, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress toward Millennium Development Goal 4. Lancet. 2010;375:1988-2008.

2. Murray ClL, Laakso T, Shibuya K, Hill K, Lopez AD. Can we achieve Millennium Development Goal4? New analysis of country trends and forecasts ofunder-5 mortality to 2015. Lancet. 2007;370:1040-1054.

3. World development indicators database. Washington DC: World Bank. 4. Black RE, Cousens S, Johnson HL, et al.; Child Health Epidemiology Research

Group (CHERG) of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375:1969-1987.

5. Black RE, Allen LH, Bhutta ZA, et al.; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371 :243-260.

6. Neonatal and perinatal mortality: country, regional and global estimates. Geneva: WHO; 2006.

7. State of the world's children 2012. New York: UNICEF; 2012. 8. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, Bernis L; Lancet Neonatal

Survival Steering Team. Evidence-based, cost-effective interventions: how many new- born babies can we save? Lancet. 2005;365:977-985.

9. Prtiss-Ustiin A, Corvalan C. How much disease burden can be prevented by environ- mental interventions? Epidemiology. 2007;18:167-l78.

10. Diarrhoea: why children are dying and what can be done. New York/Geneva: WHOI UNICEF; 2009.

11. Boschi-Pinto C, Velebit L, Shibuya K. Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ. 2008;86:710-717.

12. Fischer Waler CL, Black RE. Zinc for the treatment of diarrhoea: effect on diar- rhoea morbidity, mortality and incidence of future episodes. Int J Epidemiol. 20 I 0;39 (suppl 1 ):i63-i69.

13. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86:408--416.

14. Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS; Measles Initiative. Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study. Lancet. 2005;369:191-200.

15. van den Ent MMVX, Brown DW, Hoekstra EJ, Christie A, Cochi SL. Measles mortality reduction contributes substantially to reduction of all cause mortality among children less than five years of age, 1990-2008. J Infect Dis. 2011; 104(suppll):SI8-S23.

108 CHAPTER 5 CHILD HEALTH

16. Recommended routine immunization: summary of WHO position papers. Geneva: WHO; 2010.

17. 2011 childhood & adolescent immunization schedules. Atlanta GA: CDC; 2011. 18. Hanson LA. Feeding and infant development: breast-feeding and immune function.

Proc Nutr Soc. 2007;66:384-396. 19. Complementary feeding: report of the global consultation, and summary of guiding

principles for complementary feeding of the breastfed child. Geneva: WHO; 2002. 20. Brady JP. Marketing breast milk substitutes: problems and perils throughout the world.

Arch Dis Child. 2012;97:529-532. 21. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health

Organization; 1981. Retrieved from http://www.who.intlnutritionlpublications/code_ english. pdf

22. Cueto M. The origins of primary health care and selective primary health care. Am J Public Health. 2004;94:1864-1874.

23. Claeson M, Waldman RJ. The evolution of child health programmes in develop- ing countries: from targeting diseases to targeting people. Bull World Health Organ. 2000;78:1234-1245.

24. Msuya J. Horizontal and vertical delivery of health services: what are the trade offs? Washington DC: World Bank; 2004.

25. Lambrechts T, Bryce J, Orinda V. Integrated management of childhood illness: a summary of first experiences. Bull World Health Organ. 1999;77:582-594.

26. Child health in the community- "community IMC!" briefing package for facilitators. Geneva: WHO; 2004.

27. International Programme on the Elimination of Child Labour (IPEC). Children in hazardous work: what we know, what we need to do. Geneva: ILO; 2011.

28. The Platform for Action, UN Fourth World Conference on Women; 1995. 29. World report on disability 2011. Geneva: WHO; 2011.

l-IEALTH IN EARl,1{

It is fairly easy to summarize the main causes of disease, disability, and death for children (poverty) and older adults (chronic diseases), but the health risk profile for young adults varies considerably by sex and in different parts of the world. For example, HIV I AIDS is the leading cause of death of reproductive-age adults in Africa, while cardiovascular disease is the most common cause of mortality among younger adults in Europe. 1 Even so, there are several common issues that young adults face across the globe. The leading causes of morbidity, mortality, and disability of young adults worldwide include mental health disorders, injuries (primarily due to road-traffic accidents), infectious diseases, and pregnancy-related conditions (Tab!e 6_.1).2.3 As adults age, the primary causes of death shift from injuries, HIV/AIDS, and suicide to heart disease and stroke (Tabh:: J

6.2 HEALTH

Neuropsychiatric conditions such as depression, bipolar disorder, and schizophrenia are the leading cause of disability in young adults in every region of the world, accounting for about half of all lost disability-adjusted life years (DALYs).2 Some mental health disorders cause only occasional interference with normal activities, but others are severe and cause extreme disability. For example, people with schizophrenia may have distorted

109

110 CHAPTER 6 HEALTH OF YOUNGER ADULTS

Table 6-1 Top five causes of morbidity and mortality in adolescents and young adults worldwide, by sex and age, in 2004, with mental health and injury-related conditions shaded in grey.

Leading Causes of Illness and Disability

Leading Causes of Death

Females Males

15-19 years 20-24 years 15-19 years 20-24 years

4 Tuberculosis

Tuberculosis

Source: Data from Gore FM, Bloem PJ, Patton GC, et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet. 2011 ;377: 2093-2102; and Patton GC, Coffey C, Sawyer SM, et al. Global patterns of mortality in young people: a systematic analysis of population health data. Lancet. 2009;374:881-892.

perceptions of reality (including hallucinations and delusions) that cause them to be socially excluded or to isolate themselves from others. People with severe depression may not have the energy to get out of bed, eat, go to work, meet with friends, or conduct other normal daily activities.

6.2 Mental Health 111

Table !fh2 Major causes of death for young and middle-aged adults, by age and sex in 2004.

Females Males

15-29 30-44 45-59 15-29 30-44- 45-59 years years years years years years

HIV/AIDS HIV/AIOS Ischemic Road-traffic HIVIAIDS Ischemic heart accidents heart disease disease

TB TB Stroke Violence Road-traffic Stroke accidents

Self- Self- HIV/AIDS HIV/AIDS TB HIVIAIDS inflicted inflicted injuries injuries

Road-traffic Ischemic Breast Self- Ischemic COPD accidents heart cancer inflicted heart

disease injuries disease

Fires Road-traffic COPD TB Violence Lung accidents cancer

Maternal Diabetes Self- TB hemorrhage inflicted

injuries

COPD: Chronic obstructive pulmonary disease; TB: tuberculosis

Source: Data from The global burden of disease: 2004 update. Geneva: WHO; 2008.

A survey of mental health conducted in more than a dozen diverse countries estimated that between 1 % and 4% of the populations of most countries had serious mental illnesses, and approximately 9% to 17% of those surveyed reported having at least one episode of a mental illness in the 12 months before the survey.4 Worldwide, more than 450 million people have a psychi- atric disorder, including about 120 million with depression, 70 million with alcohol dependence, 40 million with dementia,and 25 million with schizo- phrenia.s Mental and behavioral health disorders account for at least 12% of the global burden of disease and cause as many days of lost work as physical illnesses.s Nearly 1 million people commit suicide each year, and 10 million to 20 million make a suicide attempt.s

In many communities, people with mental illness are treated badly.6 They may be imprisoned or involuntarily detained in hospitals for long periods of time without any legal recourse, or they may be denied access

112 CHAPTER 6 HEALTH OF YOUNGER ADULTS

to hospitalization when it is needed. Some people with mental illness are subjected to forced labor and some are physically or sexually abused. And because of poverty and discrimination, many people with mental illnesses do not have access to the health care that could improve their mental and physical health status.

Many mental illnesses are treatable. Medications can relieve symp- toms and prevent relapses, therapy can help those with mental illnesses to understand and change their thoughts and behaviors, and social rehabilita- tion that focuses on practical skills can help people with mental illnesses return to normal living activities. Unfortunately, mental health therapies are extremely underused. Considerably fewer than half of adults with severe mental illnesses receive any mental healthcare services, and an even lower proportion of those with mild or moderate mental illness receive medical care. 7 Many people do not know that help is available and so they do not seek clinical help. For others, the stigma of being diagnosed with a mental illness prevents them from seeking treatment. And many people who would like mental health assistance do not have access to a mental health special- ist. In most African and Asian countries there are more than 100,000 people for everyone psychiatrist 8 The risk factors for mental illness include living in poverty, experiencing a conflict or disaster, and having a major physical disease, so the populations that have the greatest need for mental health services often have the least access to them.

14.-----~------------------------------~

a USA South Poland Brazil China India Kenya Sierra

Korea Leone

E:l Total number of mental health hospital beds per 10,000 people

i\1ij Psychiatrists per 100,000 people

6c ·,1 Healthcare resources for severe mental illnesses in 2005. Source: Data from Jacob KS, Sharan P, Mirza I, et al. Mental health systems in countries: where are we now? Lancet. 2007;370:1061-1077.

6.3 Injuries 113

The public health actions for improving mental health care include educating the public about mental illness, providing mental health treatment as part of primary health care, and involving communities and families in caring for people with mental illnesses. When a support system is in place and the public sector (including the healthcare, education, and justice systems) as well as private employers are prepared to work with persons with mental health conditions, an environment can be created in which most people with mental illnesses can participate in the economy, be included in social events, and be protected from discrimination and violence. 9

INJURIES

The all-cause mortality rates for both young men and young women have decreased in recent decades (F'igure 6" .. 2),10 but young men continue to have a higher likelihood of death than young women. Much of this difference is due to the higher rate of injuries in males. 1 Males are significantly more likely than females to die from all major types of injuries other than bums (l?igure 6_<3).11 This disparity is due to men being more likely than women to work in hazardous occupations, to participate in dangerous recreational

1111970 30 1111990

D 2010 20 - - ,--- ,-- r-

o ~ ~ - ~ =-

11 21

C/)J1

, C/) C/) C/) C/) C/) C/) C/) C/) C/) C/) C/) C/)

<Il <Il (J.l (J.l (J.l (J.l <Il (J.l (J.l Q) Q) (j) Q) Q) ill Q) co co co co co co co co co co co co co co co co E E E E E E E E E E E E E E E E 2 2 2 2 2 2 2 2 USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 6-2 Probability of a 15 year old dying before age 60.

Source: Data from Rajaratnam JK, Marcus JR, Levin-Rector A, et al. Worldwide mortality in men and women aged 15-59 years from 1970 to 2010: a systematic analysis. Lancet. 2010;375:1704-1720.

114 6 HEALTH OF YOUNGER ADULTS

3 -it!

0 <:I <:I C

2 , ,

iii 0. W 1ii ... ~

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, U (j) (j) !!2 (j) (j) ~- (j) "D (j) (j) ~~ ~~E OJ Cii ~ OJ (j) <0 Q) Q) Q) U C .~ :5 §.t:: .2"§ c o <0 Q) <c LL u:: Q) ~ c a:l::;~ c o 'E .§-

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Unintentional Injuries Intentional Injuries

6~3 Sex-specific annual death rate per 10,000 people for specific injury- related causes worldwide in 2008.

Source: Data from The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011.

activities, to spend time on the road, to use alcohol, and to be involved armed conflict. (Women spend more time cooking than men do, so women are more likely to fall into fires or scald themselves by dropping a pot of boiling liquid.)

However, females are more likely than males to be the victims of domes- tic violence (violence by intimate partners and family members) and other acts of physical aggression, including rape, and the rate of injuries due to physical and sexual violence is probably significantly under-reported. In a multi-country study of violence against women, 15% to 71 % of women of reproductive age (15 to 49 years old) at each study site reported having been physically or sexually abused by an intimate partner. 12 In that same study, a large number of women indicated that they believed that a man has good reason to beat his wife if she does not complete housework, disobeys her husband, is unfaithful, or if the husband suspects infidelity.13 Many women reported that they did not think it was acceptable for a woman to refuse sex with her husband even if she did not want to have sex, her partner was drunk or mistreating her, or she was sick.

Females may have little power over their own bodies both because of gender norms that give men authority over women and because women

6.4 Sex, Gender, and Health 115

Tabie 6-~3 Examples of violence against women throughout the life cycle.

Phase Type of Violence

Prebirth and .. Sex-selective abortion

Infancy .. Effects of battering during pregnancy on birth outcomes

.. Female infanticide

Girlhood .. Physical, sexual, and psychological abuse by family members and acquaintances (child abuse)

., Female genital mutilation (FGM)

'" Forced sexual initiation (including child marriage)

., Child prostitution and pornography

Adolescence .. Physical, sexual, and psychological abuse by family members and Adulthood

.. Dating and courtship violence (including acid throwing and date rape)

" Intimate partner abuse (including dowry abuse, honor killings, marital rape, and forced pregnancy)

" Forced prostitution (including trafficking)

" Nonpartner coerced sex, including rape

Source: Information from Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet. 2002;359:1232-1237.

tend to be smaller and physically weaker than men. The immediate health consequences of violence against women include serious injuries, death, damage caused to fetuses when pregnant women are attacked, and psy- chological trauma. Sexually abused women may also have an unwanted pregnancy or contract sexually transmitted infections (STIs), including HIV. Violence against females may occur at any stage of their lives

6·~3).14

HEALTH

Men and women face different health challenges because of both biolog- ical characteristics related to sex and social structures related to gender. 15

Sex refers to the biological classification of people as male or female based on genetics (the presence of XX or XY sex chromosomes) and reproductive anatomy. Males and females also have somewhat different body chemistry, hormones, physiology, and brain function. These differences mean that

116 CHAPTER 6 HEALTH OF YOUNGER ADULTS

men and women sometimes have different symptoms for the same disease and different prognoses and pathways to recovery. For example, men are more likely to have "dramatic" heart attacks with crushing chest pain, while women often have subtle symptoms like feeling more tired than normal, and this difference is a key reason why heart disease in women has traditionally been under diagnosed. 16 There are many other significant differ- ences in health risks between the sexes 17 and these differences must be considered when planning for and implementing health education and preventive, diagnostic, and therapeutic health services.

',~;H'-R"~ refers to social, cultural, and psychological aspects of being male or female, and is shaped by the sociocultural environment and experience in addition to biology. There is tremendous variability in the

Table 6-4 Comparison of the burden of disease for women and men. Although all of these conditions occur in both females and males, the risk of developing these conditions varies by sex.

Women Are More Likely Than Men To ... Men Are More Ukely Than Women To ...

· .. have cancers of the reproductive system

· .. have complications from sexually transmitted infections like chlamydia and gonorrhea

· .. die from burns

· .. have depressive disorder, posttraumatic stress disorder, paniC disorder, and migraines

· .. develop vision problems related to glaucoma, cataracts, and trachoma

· .. have Alzheimer's and other dementias

· .. die from diabetes

· .. develop musculoskeletal dis- orders like rheumatoid arthritis and osteoarthritis

.. develop autoimmune disease like Lupus

· .. develop iron-deficiency anemia

· .. live to very old age

· .. have lung, bladder, mouth, esophageal, and stomach cancer

· .. become infected with trypanoso- miasis, schistosomiasis, leishmaniasis, lymphatic filariasis, and other tropical infections

· .. die from traffic accidents, poisonings, falls, drowning, violence, and war

· .. commit suicide and have drug-use disorders

· .. develop liver disorders such as cirrhosis, hepatitis B, and hepatitis C

· .. have lung diseases like TB and COPD (chronic obstructive pulmonary disease)

Source: Data from World health report 2004. Geneva: WHO; 2004.

6.5 Reproductive Health and Maternal Mortality 117

way individual women and individual men express their gender and in the ways cultures define gender roles. Gende:r roles describe how a cul- ture believes men and women should behave. For example, gender roles may indicate what tasks women are expected to do, such as cooking, cleaning, and taking care of children. They may also define what tasks women cannot do, which might include working with heavy HHU",LnH'v~ being in religious leadership, or driving cars. Traditional cultures often consider women to be under the authority of their fathers (or other male relatives) until marriage and of their husbands after marriage, and may limit the ability of a woman to own property or manage her own finances. Some cultures have strict rules about what women can wear in public and whether they can be in public spaces unaccompanied by a male. This can limit the ability of women to participate in the marketplace and government, to attend school and religious meetings, and to acquire medical attention and information. Gender roles also define the social and behavioral norms for men. For example, young men may feel pressure to engage in risky behaviors like reckless driving or tobacco use in order to demonstrate their masculinity.

6,,5 HEALTI-I AND MATERNAL

encompasses issues of safe sex, prevention and treatment of sexually transmitted infections, contraception, fertility and infertility, sexual health, pregnancy, and childbirth. Reprodu.ctive health is a critical issue for both men and women who are young adults. Both men and women need to have access to reproductive health care and the tools to maintain their reproductive health. And both men and women need to be aware of the risks associated with childbearing.

For many pregnant women, the hours of labor and delivery are precari- ous ones. Pregnancy and childbirth are still among the leading causes of death among women of reproductive age in low-income countries. About 350,000 women worldwide die each year as a result of pregnancy or child- birth, which translates to nearly 40 deaths every hour. 18 The most common cause of m:f![ern:!X mo.rtaUi:y-death during pregnancy, childbirth, or soon after-is severe postpartum bleeding (heu-ronhage) (Figure 6~4). Other common causes of maternal death inclu.de (which starts as pre- eclampsia, characterized by high blood pressure and protein in the urine, and can develop into convulsions and possible organ failure), unsafe abortions, infections (like sepsis, an infection of the blood), and obstructed labor. 19,20

118 CHAPTER

Embolism 1%

HEALTH OF YOUNGER ADULTS

6-4 Causes of maternal death in 2005.

Source: Data from Countdown to 2015 decade report (2000-2010): taking stock of maternal, newborn and child survival. Geneva: WHO/UNICEF; 2010; and Khan KS, Wojdyla D, Say L, Gi.iImezoglu AM, Van Look PFA. WHO analysis of causes of mater- nal death: a systematic review. Lancet. 2006;367:1066-1074.

Each pregnancy carries risks, but pregnancy is especially risky when a woman has existing health problems, has had a high-risk pregnancy in the past, is having twins or higher numbers of children, or will not have access to a trained birth attendant.

The difference in risk of maternal death between high-income and low- income regions is huge. In Sierra Leone, one of the poorer countries in sub-Saharan Africa, more than 900 women die for every 100,000 births, compared to about 20 maternal deaths for every 100,000 births in the United States 21 Most women in Sierra Leone have sev- eral pregnancies, so the lifetime risk of maternal death is about 1 in 23. In the United States, where women tend to have fewer pregnancies and a lower risk of death for each pregnancy, the lifetime risk of maternal death is about 1 in 2400. 22 On average, women in sub-Saharan Africa are about 140 times more likely to die while giving birth than women in the United States, Canada, or Europe 23 There are also signifi- cant variations in the maternal mortality rate within most countries, with higher-income women experiencing a much lower mortality rate than lower-income women. 24

6.5 Reproductive Health and Maternal Mortality 119

1400,-----------------~----------------------------~

1200+-------------------------------------------

1000+-------------------------------------------

800+-------------------------------------------

600+-------------------------------

400+-------------------------------

200+-----------------------~=_----

O~=-~~~--~~~~illE.,~~~

USA South Poland Brazil China India Kenya Sierra Korea Leone

ml1980 01990 il!iI2000 Il! 201 0

6·-5 Number of deaths of women from pregnancy-related causes per 100,000 live births between 1980 and 2010.

Source: Data from Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development GoalS. Lancet. 2010;375:1609-1623; and Trends in maternal mortality: 1990 to 2010. Geneva: WHO, UNICEF, UNFPA, World Bank; 2012.

1 in 2400 1 in 4800

USA South Korea

Poland

1 in 910 1 in 1700 1 in 170 1 in 55

Brazil China India Kenya

1 in 23

Sierra Leone

6-·6 Lifetime risk of death due to pregnancy-related causes for women as of 2010.

Source: Data from Trends in maternal mortality: 1990 to 2010. Geneva: WHO, UNICEF, UNFPA, World Bank; 2012.

Many of these deaths could have been prevented if the women had access to advanced medical care. However, about one-third of women worldwide-- including half of women in sub-Saharan Africa and South Asia--give birth without the assistance of a skilled birth attendant (sometimes called a trained

120 CHAPTER 6 HEALTH OF YOUNGER ADULTS

birth attendant, or TBA), such as a nurse or midwife, who is trained to man- age complications 6-7)?1 Maternal healthcare workers also facilitate the reproductive health of women more generally by educating women and men about contraceptives and child spacing, increasing access to prenatal care and delivery assistance, and fostering conditions in which women can make informed health decisions for themselves.

Women who survive pregnancy and delivery complications may be left with permanent disabilities. For example, some women who are small, as is often the case with girls who become pregnant in their early teenage years, develop a condition called obstructed labor, which is when the unborn baby is wedged so tightly into the birth canal that blood flow to surrounding tis- sues is cut off and the tissue starts to die. Women who are able to get to a hospital can have surgery (a Cesarean section) to deliver the baby before too much damage is done. Women who do not have access to a surgeon may be in labor for several days. The outcome, if the woman survives, is often the formation of an a hole between the rectum or bladder and the vagina that constantly leaks urine or feces. Because of the odor, most women with an obstetric fistula are ostracized by their communities. Some women are left paralyzed because of nerve damage and many are left infertile. In nearly all of these cases the baby is stillborn. About 3 million women worldwide are estimated to be living with an obstetric fistula, and

USA South Poland Brazil China India Kenya Sierra Korea Leone

6-7 Percentage of births attended by skilled personnel (doctors, nurses, or midwives) between 2006 and 2010.

Source: Data from State of the world's children 2012. New York: UNICEF; 2012.

6.5 Reproductive Health and Maternal Mortality 121

more than 50,000 new cases occur every year. 25 Fistulas can be surgically corrected, but the better option is preventing obstructed labor by delaying pregnancy until women are fully grown and by ensuring access to medical professionals during delivery if help is needed.

Women who have been circumcised (also called female genital cutting, female genital mutilation, or FGM), a common practice in some parts of Africa and the Middle East, have particularly high risks of adverse reproduc- tive health outcomes, including a greater risk of infection, te31ing during deliv- ery, and postpartum hemorrhage, and a greater need for Caesarean sections. 26

Safe motherhood programs need to address issues from prior to conception through the time after delivery 27,28 All women and men of reproductive age need to have access to information about reproduction and contraception so they are better prepared to make decisions about sex and are able to prevent unwanted pregnancies, unsafe abortions, and sexually transmitted infections. During pregnancy, women need information about how to stay healthy, eat well, and recognize potential complications so they can be addressed as soon as possible.

Table ,:;-5 Preventive and treatment interventions for maternal mortality.

Preventive Interventions (promoting healthy pregnancies)

" Family planning/birth spacing

.. Diagnosis and treatment of medical conditions that could complicate a healthy pregnancy, such as anemia, asthma, diabetes, heart disease, hypertension, or infections

.. Iron and folic acid supplements, deworming treatment, and malaria treatment to prevent or treat anemia

" Antiretroviral drugs for women with HIV infection

" Calcium supplements for women at high risk of pre-eclampsia

.. Tetanus toxoid immunization

Treatment Interventions (addressing birth complications)

@ Detection and management of pregnancy complications such as pre-eclampsia

" Antibiotics for premature rupture of membranes to prevent sepsis

9 Skilled attendants during labor, delivery, and the postpartum stage

" Early detection oI postpartum maternal complications such as hemorrhage

'" Early referral to professional obstetric care for women experiencing maternal complications during pregnancy, labor, delivery, or after delivery

Source: Data from Campbell OMR, Graham WJ; Tile Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368: 1284-1299.

122 CHAPTER 6 HEALTH OF YOUNGER ADULTS

All deliveries should be attended by a trained healthcare provider, the woman and her baby should be observed after delivery, and both should be examined several weeks later to be sure that they are recovering and healthy.

Family planning is an important decision for both young men and young women. Women and their babies are usually healthier when women have fewer pregnancies. Mothers, babies, and children also benefit from llYirth

When the time between the birth of one baby and the next one is short, the older baby is at risk for malnutrition because of being weaned from breastmilk at a young age and having fewer household resources per child, and the younger baby has an increased risk of low birthweight and preterm birth. 29 ,3o helps women and men to make deci- sions about how many children they want to have and how many years apart they want those pregnancies to be.

<""",y."",,",,, is the intentional prevention of pregnancy. Contraceptive methods include abstinence, barriers, medications, and surgery?! Complete sexual abstinence is the only guaranteed way to prevent pregnancy. Some couples practice periodic abstinence and avoid intercourse during the days after a woman ovulates (when an egg is released from an ovary), the time when a woman is most fertile, but this is an imperfect method.

Condoms and diaphragms are used as a physical barrier during sexual intercourse to prevent sperm from coming into contact with an egg.

Oral contraceptives (birth control pills) prevent ovulation when taken as prescribed, so no eggs are released from the ovaries and a pregnancy cannot occur. In many parts of the world, oral contraceptives are called the "family planning pill" in recognition of their importance for birth spacing. Oral con- traceptive pills must be taken at the same time every day, without skipping any doses, for this method to be effective. Some women prefer a longer-term method of pregnancy prevention and choose hormonal contraceptives that are delivered through a weekly patch, monthly injections, or vials placed under the skin of the upper arm that release medication for up to 5 years.

IUDs (intrauterine devices) prevent fertilization of eggs by creating a uterine environment that is unfavorable to sperm (which must pass through the uterus to reach unfertilized eggs). IUDs may also inhibit the implanta- tion of fertilized eggs in the endometrium that lines the uterus. For perma- nent sterilization, women can opt to have tubal ligation surgery and men may choose to have vasectomies. The relative effectiveness of a variety of contraceptive methods is shown in Tab!e 6~6.

T8lbk~ 6~6 Contraceptive methods.

Approximate Protection Pregnancy Rate in Against Sexually 1 st Year of Typical Transmitted

Type Approach (not perfect) Use Infections? Notes

Complete abstinence Abstinence 0% Yes No intercourse Male sterilization (vasectomy) surgery -0% No Permanent

Subdermal implant contraceptives Hormones -0% No Effective for about 3 to 5 years after implantation

Female sterilization (tubal ligation) Surgery <1% No Permanent

Intrauterine device (IUD) IUD <1-2% No Effective for 5 or more years after insertion

Injection contraceptives Hormones <1-3% No One injection every 1 to 3 months

Oral contraceptives Hormones 8% No Pill must be taken daily to be effective

Transdermal (patch) contraceptives Hormones 8% No The patch must be replaced weekly

Intravaginal (ring) contraceptives Hormones 8% No The vaginal ring must be replaced monthly

Male condom Barrier 15% Yes Must be used during every act of intercourse

Diaphragm or cervical cap with Barrier + 20% No Must be used during every act of intercourse spermicide spermicide Female condom Barrier 21% Some Must be used during every act of intercourse

Spermicide alone Spermicide 29% No Must be used during every act of intercourse

Periodic abstinence (fertility- Behavior 12-25% No Requires daily monitoring of body func- awareness-based methods) tions and periods of abstinence Withdrawal method Behavior 27% No Must be used during every act of

intercourse No contraceptive method used None 85% No

Source: Data from Black KI, Gupta S, Rassi A, Kubba A. Why do women experience untimed pregnancies? A review of contraceptive failure rates. Best Pract Res C/in Obstet Gynaecol. 2010;24:443-455.

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124 CHAPTER 6 HEALTH OF YOUNGER ADULTS

100--------------------------------------------------~

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Korea Leone

6--3 Proportion of sexually active women ages 15 to 49 using contra- ceptives between 2006 and 2010.

Source: Data from State a/the world's children 2012. New York: UNICEF; 2012.

is the tennination or loss of a pregnancy. (Miscarriages are called spontaneous abortions by medical professionals.) Induced abortions are chemically or surgically terminated pregnancies. Abortions are not a form of contraception because they end a pregnancy rather than prevent it. Increased access to contraception reduces the number of induced abortions by preventing unplanned pregnancies.

Many sexually active reproductive-age women and men around the world do not use any contraceptive method 21 Because only abstinence and condoms help to prevent the spread of sexually transmitted infections (STIs), all sexually active people of all ages--even women who are not able to become pregnant and men who are infertile--are encouraged to consider what methods they will use to prevent STls.

There are a number of different ways to report a woman's reproductive history. refers to the total number of times a woman has been pregnant, and includes miscarriages, abortions, stillbirths, and births.

is the total number of births, whether the result was a stillbirth or a live birth. refers to the total number of live births. Because very few miscarriages and abortions are reported to healthcare professionals,

6. 7 Fertility 125

most global health reports use fertility to measure pregnancies in a popula- tion. The goal of family planning is to minimize unplanned pregnancies (to reduce gravidity) and to maximize the health of babies from pregnancies that do occur (so that parity is as close as possible to gravidity).

The :rate is the average number of children a woman gives birth to during her childbearing years. In most countries the fertility rate has decreased significantly in recent decades 21,23 Still, in general, lower-income countries have much higher fertility rates than higher-income countries (Figure 32 One of the best predictors of decreased fertil- ity is increased female education 6~11)?2 Educated women have smaller families for many reasons. One is that the work outside the home that is made possible by literacy may delay marriage and a first pregnancy. Another reason is that educated women can make better decisions about contraception and childbearing with their partners because they have the ability to read and act on information about good health practices, nutrition, disease prevention, and child-rearing strategies.

The fertility rate has an impact on population health, not just the health of individual women, babies, and families. If each woman has, on aver- age, about 2 children (and those children live to adulthood), then each couple will produce only a (2 parents producing

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IJ 1970

IJ 1990

EJ 2010

6~9 Total fertility rates between 1970 and 2010. A fertility rate less than 2 is below replacement levels.

Source: Data from State of the world's children 2012. New York: UNICEF; 2012; and State of the world's children 2011. New York: UNICEF; 2011.

6~-lG Fertility rates (births per woman) in 2010.

Source: Data from World development indicators database. Washington DC: World Bank.

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6.7 Fertility 127

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Source: Data from World development indicators database. Washington DC: World Bank.

2 offspring), and over the generations the population size will remain about the same. If the total fertility rate is greater than 2, then the size of the population will increase over time. If the fertility rate is than 2, then the average age of the population will increase and the number of people in the total population will begin to decrease. (These stages are part of the demographic transition associated with economic development.) The high fertility rates in some parts of the world, and the low rates in others, have created concerns about global population growth and about appropriate policies for promoting healthy fertility rates.

Reproductive rights have been a controversial topic on the global health agenda. For example, when the Cairo Conference on Population and Development in 1994 focused on women's empowerment and reproduc- tive rights-and, more specifically, on the ability of a woman or couple to decide how many children they want without interference from govern- ments or other organizations-it sparked the concern of religious groups. The Roman Catholic Church was particularly vocal about the use of con- traceptives and possible increases in the number of induced abortions.

Even so, most communities now recognize the importance of all adults and adolescents, both males and females, understanding their options for contraception and family spacing. Population planning programs target both women and men because household reproductive decisions involve both paItners, and because a woman whose partner does not want her to use

128 CHAPTER 6 HEALTH OF YOUNGER ADULTS

contraception will often follow her partner's wishes. Although millions of people who would like to use contraception do not have access to family planning services, thousands of healthcare providers, governments, part- ners ofthe United Nations Population Fund (UNFPA, formerly the United Nations Fund for Population Activities), Planned Parenthood affiliates, and other organizations seek to bring information and supplies to men and women worldwide who want to make informed reproductive decisions.

Picture a small island in the middle of an ocean. It is arable (can grow food) and has a variety of plant animal species. Say that at first 10 people settle on the island. They build homes, develop a system for collecting freshwater (because ocean water is too salty to drink or to use for irrigation), and begin to farm the land. They also begin to have children, and eventu- ally those children have children. Soon the population has reached 100, and then it grows to 1000. The amount of land available for farming decreases as more homes are built, yet the need for food is greater because there are more people to feed. Getting rid of waste products and finding energy sources are growing problems. The limited amount of freshwater available is becoming a source of stress as the demand for water increases, but water quality becomes poorer as waste pollutes water sources. Some plants and animals are threatened and at risk of extinction. Crime is increasing as resources become scarce. What would happen if the population increased to 10,000, or to a million? Is there a limit to the number of people a small island could support?

Many people have similar concerns about the growth of the global human population. For a long time the size of the Earth's population was relatively steady, but recent population growth has been exponen- tial. 6~ 12 is a plot of the size of the world's human population over time, and it shows a "J-shaped" growth pattern. After many years of relatively limited population growth, there has been a very steep increase in the total world population in recent centuries. The doubling time, the number of years it takes for the world's population to double, is getting shorter. It took only 40 years-from 1950 until 1 990-for the number of humans to double from 2.5 billion to 5 billion. The current world population is approximately 7 billion, and it is expected to level off at about 9 billion by 2100?4

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6.8 Population Growth 129

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Figure 6~-12 World population growth over time.

Source: Data from United Nations Department of Economic and Social Affairs. World population to 2300. New York: UN; 2004.

Ca:r:rying is the maximum human population the Earth can sus- tain. There is no easy way to calculate carrying capacity because it depends on the standard of living and cultural factors in addition to population den- sity (measured as land area per person or as arable land area per person), climate, and the land and natural resources that are available. Carrying capacity can be approximated with estimates based on the per capita area of land needed to meet a population's consumption patterns (Figtm: 35 Earth could likely not support the current world population if everyone had the current ecological footprint of the United States, but most countries aspire to higher standards of living that come with larger ecological footprints.

So what will happen if the world population continues to grow? One famous scenario was proposed in 1798 by Thomas Malthus, who pre- dicted that at some point the population would exceed food supply, and the result would be mass famine, epidemics, and war. 36 These (~ata~:tn[)jpj!Jle§ have not occurred, and at present global food production is growing faster than the population. However, food and other resources are not distributed equally, and fertility rates and popUlation growth are high- est in the poorest parts of the world where food production is often low. There are valid reasons to be concerned about the unequal distribution of

130 CHAPTER 6 HEAL TH OF YOUNGER ADULTS

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6~13 Average ecological footprints in 2007.

Source: Data from Ewing B, Moore D, Goldfinger S, Oursler A, Reed A, Wackernagel M. The Ecological Footprint Atlas 2010. Oakland, CA: Global Footprint Network; 2010.

food and natural resources, the risks of increased pollution and congestion that will occur with continued population growth, and the possibility of increased crime and war as resources in some regions of the world become scarce. One check on exponential growth is that fertility rates generally decrease when economic conditions in a improve. Another check is the increased use of modern family planning methods.

The goal of population planning policies at the regional, national, and international levels is to promote a popUlation growth rate in line with desired demographic and socioeconomic profiles. In most lower-income countries, population policies focus on encouraging reduced fertility rates

6~ 37 Middle-income countries generally view their growth rates as satisfactory. And in some high-income countries where fertility rates are below replacement level and popUlation aging is a concern, the goal of population policies is to provide incentives for increased fertility. Effective population planning policies often aim to increase the ability of women and men to choose how many children they want and how they want to space their children's births.

Iabhs: 6~7 Population policies.

South Sierra Country USA Korea Poland Brazil China India Kenya Leone

Annual Growth Rate 1.0% 0.6% 0.0% 1.3% 0.8% 1.7% 2.7% 1.9% (1990-2010)

Expected Annual 0.8% 0.2% -0.1% 0.6% 0.2% 1.1% 2.4% 1.9% Growth Rate (2010-2030)

Total Fertility Rate 2.1 1.3 1.4 1.8 1.6 2.6 4.7 5.0 (2010)

View on Population Satisfactory Too low Too low Satisfactory Satisfactory Too Too Too high Growth/Fertility Level high high

Policy on Population No Raise Raise No Maintain Lower Lower Lower G rowth/F erti I ity intervention intervention

Source: Data from United Nations Department of Economic and Social Affairs. World population policies 2009. New York: UN; 2010.

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132 CHAPTER 6 HEALTH OF YOUNGER ADULTS

Nearly all low-income countries have relatively high fertility rates. To promote reduced fertility, most low-income countries provide direct gov- ernment support for the distribution of family planning information and contraceptives,37 but their specific policies vary. For example, Kenya has had a government population policy since 1967, and since 2005 has allo- cated government funds directly for contraceptives in order to improve infant and maternal survivat 38 Many of Kenya's population policies stem from the Kilimanjaro Programme of Action adopted at the Second African Population Conference, which met in Arusha, Tanzania, in 1984, and provided a framework for population policies on the African continent. The recommendations of the Arusha Conference stated that governments should acknowledge that family planning and child spacing strengthen families, that family planning services should be incorporated into mater- nal healthcare services, that governments should ensure access to family planning for aU individuals seeking it and should offer services at free or subsidized prices, and that a variety of family planning methods should be made available to users. As a comparison, India has had government- sponsored family planning programs since 1951, and has shifted from an original focus on the distribution of barrier contraceptives to an emphasis on sterilization, especially sterilization of relatively young women, along with a focus on birth spacing. 39

China has been one of the most aggressive countries in limiting popula- tion growth. The "late, long, few" policy of the 1970s encouraged delayed childbearing, longer spacing between children, and fewer children, and cut the total fertility rate in half. The goal of China's one-child policy, which was adopted in 1979, is to use economic and educational incen- tives to promote one-child families, especially in urban areas. Because there are exemptions to the policy for rural residents, for highly edu- cated or wealthy parents, for parents who are both only children, and for some minority groups, the actual fertility rate in China is currently about 1.8 children per couple, not 1 child per couple. 40 The program has been controversial since its inception because of reports that, despite official policy, there have been instances of forced abortions and sterilizations, infanticide (especially of females in rural areas), and other human rights abuses. Another concern is that the preference for male children may have made sex-selective abortions common enough to skew male-female birth ratios (even though the Chinese government expresses a commitment to equalizing its sex ratio ).41,42 Within China, the main concern is that there are now many families with a "one-two-four" structure-only one grandchild to support two parents and four grandparents.43 Still, as a result of those

6.10 Discussion Questions 133

policies and programs, China now has what it deems to be a satisfactory population growth and fertility rate.

As a comparison with another middle-income country, Brazil's fertil- ity rate has also decreased significantly in recent decades even though few formal government policies have promoted contraceptive use. The first agencies in Brazil that provided reproductive health services were nongovernmental organizations founded in the 1960s to address some of the demands for family planning. In the 1980s, the Ministry of Health initiated several maternal health programs that focused on comprehensive health care rather than emphasizing fertility control. in the 2000s did the federal government expand its commitment to supplying free or low- cost contraceptives to reproductive-age men and women and to increasing access to both sterilization surgery and infertility treatment. 44

Higher-income countries have a different emphasis: most want to pro- mote higher fertility rates. South Korea has one of the lowest fertility rates in the world, which prompted the government of the Republic of Korea to drop policies promoting low fertility rates in 1996. In 2006, the government introduced a new plan to promote childbearing that aims to help women balance work and family responsibilities. The government covers many of the costs associated with health care for pregnant women, provides tax breaks to cover childcare costs, pays for 90 days of maternity leave, and provides a subsidy for stay-at-home parents. 45

Thus, population planning policies are designed to address country- specific needs and are responsive to changing socioeconomic and demo- graphic trends. Ideally, these policies help increase the health status of infants and children, reproductive-age adults, their families, and their communities.

1. What psychiatric and psychological health services are available in your community? Do you know where you could go to access mental health care? Do you know where you could refer a friend who was having suicidal thoughts?

2. What types of injuries are you most likely to have? What steps can you take to prevent injuries and injury-related disability?

3. What are some examples of gender roles in your community? How do these relate to health?

4. Before reading this chapter, did you consider pregnancy to be a risky time for a woman? What are the factors that account for the huge

134 CHAPTER 6 HEALTH OF YOUNGER ADULTS

difference in the risk of mate mal mortality in low-income countries and high-income countries?

5. A growing number of American women want to give birth at home instead of at a hospital. What do you think about this practice? What environment would you prefer if you were giving birth or your partner was giving birth?

6. How many children do you want to have? What influences your ideas about your ideal number of offspring?

7. Do you think that there is a limit to the number of humans who can live on Earth? What factors contribute to the ability of the Earth to sustain (or fail to sustain) a large number of humans?

1. The global burden of disease: 2004 update. Geneva: WHO; 2008. 2. Gore FM, Bloem PJ, Patton GC, et al. Global burden of disease in young people aged

10-24 years: a systematic analysis. Lancet. 2011;377:2093-2102. 3. Patton GC, Coffey C, Sawyer SM, et al. Global patterns of mortality in young people:

a systematic analysis of population health data. Lancet. 2009;374:881-892. 4. Demyttenaere K, Bruffaerts R, Posada-Villa J, et al.; WHO World Mental Health

Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. lAMA. 2004;291 :2581-2590.

5. World health report 2001. Geneva: WHO; 2001. 6. WHO resource book on mental health, human rights and legislation. Geneva: WHO;

2005. 7. Wang PS, Aguilar-Gaxiola S, Alonsa J, et al. Use of mental health services for anxiety,

mood, and substlliice disorders in 17 countries in the WHO world mental health surveys. Lancet. 2007;370:841-850.

8. Jacob KS, Sharan P, Mirza I, et al. Mental health systems in countries: where are we now? Lancet. 2007;370:1061-1077.

9. Herrman H, Saxena S, Moddie R, editors. Promoting mental health: concepts, emerging evidence, practice: summary report. Geneva: WHO; 2004.

10. Rajaratnam lK, Marcus JR, Levin-Rector A, et al. Worldwide mortality in men and women aged 15-59 years from 1970 to 2010: a systematic analysis. Lancet. 2010;375:1704-1720.

11. The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011. 12. Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH; WHO Multi-

country Study on Women's Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: findings from the WHO multi-country study on women's health and domestic violence. Lancet. 2006;368:1260-1269.

13. Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts C. WHO Multi-country Study on Women's Health and Domestic Violence against Women: Initial results on prevalence, health outcomes and women's responses. Geneva: WHO; 2005.

References l35

14. Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet. 2002;359: 1232-1237.

15. Johnson JL, Greaves L, Repta R. Better science with sex and gender: facilitating the use of a sex and gender-based analysis in health research. Int J Equity Health. 2009;8:14.

16. Arslanian-Engoren C, Engoren M. Physiological and anatomical bases for sex differ- ences in pain and nan sea as presenting symptoms of acute coronary syndromes. Heart Lung.20lO;39:386-393.

17. World health report 2004. Geneva: WHO; 2004. 18. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries,

1980-2008: a systematic analysis of progress towards Millennium Development GoalS. Lancet.20lO;375:1609-1623.

19. Countdown to 2015 decade report (2000-2010): taking stock of maternal, newborn and child survival. Geneva: WHOIUNICEF; 20lO.

20. Khan KS, Wojdyla D, Say Lm, Giilmezoglu AM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367: 1066-1074.

21. State of the world's children 2012. New York: UNICEF; 2012. 22. Trends in maternal mortality: 1990 to 2010. Geneva: WHO, UNICEF, UNFPA, World

Bank; 2012. 23. State of the world's children 2011. New York: UNICEF; 201l. 24. Ronsmans C, Graham WJ; The Lancet Maternal Survival Series steering group.

Maternal mortality: who, when, where, and why. Lancet. 2008;368:1189-1200. 25. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem.

Lancet. 2006;368:1201-1209. 26. Adam T, Bathija H, Bishai D, Bonnenfant YT, et a1.; FGM Cost Study Group of WHO.

Estimating the obstetlic costs of female genital mutilation in six African countries. Bull Wold Health Organ. 2010;88:281-288.

27. AbouZahr C. Safe motherhood: a brief history of the global movement 1947-2002. Br Med Bull. 2003;67:13-25.

28. Campbell OMR, Graham WJ; The Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368: 1284-1299.

29. Rutstein SO. Effects of preceding birth intervals on neonatal, infant and under -five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. Int J Gynaecol Obstet. 2005;89 (suppll):S7-S24.

30. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. lAMA. 2006;295:1809-1823.

31. Black KI, Gupta S, Rassi A, Kubba A. Why do women experience untimed pregnan- cies? A review of contraceptive failure rates. Best Pract Res Clin Obstet Gynaecol. 20lO;24:443--455.

32. World development indicators database. Washington DC: World Bank. 33. Skirbekk V. Fertility trends by social status. Demographic Res. 2008; 18: 145-180. 34. United Nations Department of Economic and Social Affairs. World population to 2300.

New York: UN; 2004. 35. Ewing B, Moore D, Goldfinger S, Oursler A, Reed A, Wackernagel M. The Ecological

Footprint Atlas 2010. Oakland, CA: Global Footprint Network; 20lO. 36. Malthus M. An essay on the principle of population. London: J. Johnson; 1798.

136 CHAPTER 6 HEALTH OF YOUNGER ADULTS

37. United Nations Department of Economic and Social Affairs. World population policies 2009. New York: UN; 2010.

38. Crichton J. Changing fortunes: analysis of fluctuating policy space for family planning in Kenya. Health Policy Plan. 2008;23:339-350.

39. Matthews Z, Padmadas SS, Hutter I, McEachran J, Brown JJ. Does early childbearing and a sterilization-focused family planning programme in India fuel population growth? Demographic Res. 2009;28:693-720.

40. Hesketh T, Lu L, Xing Zw. The effect of China's one-child family policy after 25 years. N Engl f Med. 2005;353:1171-1177.

41. Ding QJ, Hesketh T. Family size, fertility preferences, and sex ratio in China in the era of the one child family policy: results from national family planning and reproductive health survey. BMf. 2006;333:371-373.

42. Zhu WX, Lu L, Hesketh T. China's excess males, sex selective abortion, and one child policy: analysis of data from 2005 national intercensus survey. BMf. 2009;338:b1211.

43. Hvistendahl M. Has China outgrown the one-child policy? Science. 201 ;329: 1458-1461. 44. Diniz Alves JE. The context of family planning in Brazil. Demographic transforma-

tions and inequalities in Latin America: historical trends and recent patterns. Rio de Janeiro: UNFPA; 2009: 297-302.

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PTE 7

Declining fertility rates and increasing life expectancy have significantly increased the percentage of the world population that is 65 years of age and older 1 and that proportion is expected to continue to increase in the coming decades in every part of the world 2 The number of people aged 60 and older worldwide is expected to increase from about 700 million in 2010 to 2 billion in 2050, and the number of adults aged 80 and older is expected to increase from about 100 million in 2010 to 400 million in 2050. 3 About two-thirds of all older adults cur- rently live in less developed countries, and that proportion will increase in the coming years. 3

Many older adults live active and independent lives. However, most will at some point develop hypertension or another cardiovascular disease, diabetes, cancer, a chronic lung disease, a musculoskeletal condition such as arthritis or osteoporosis, a neuropsychiatric condition such as dementia or depression, a sensory impairment like hearing or vision loss, or several of these chronic conditions at the same time. 4 Noncommunicable diseases (NCDs) are the most common causes of death of older adults in every region of the world even though the rates of particular NCDs vary somewhat between regions 4

137

7~1 Proportion of the population 65 years of age and older in 2009.

Source: Data from World development indicators database. Washington DC: World Bank.

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7.1 Global Aging 139

USA South Poland Brazil China India Kenya Sierra Korea Leone

Ill! '=':65

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7-2 Proportion of the population by age in 2010 and projected for 2060.

Source: Data from Hughes BB, Kuhn R, Peterson CM, Rothman DS, Sol6rzano JR. Improving global health forecasting the next 50 years. Patterns of Potential Human Progress Series, Volume 3. Boulder CO: Paradigm Publishers; 2011.

100%~~-

80%

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USA South Poland Brazil China India Kenya Sierra Korea Leone

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D Noncommunicable diseases (NCDs)

Ill! Communicable diseases

7-3 Percent of deaths in adults ages 60 and older due to communicable diseases, noncommunicable diseases, and injury in 2008.

Source: Data from The global burden of disease: 2004 update (April 2011 update). Geneva: WHO; 2011.

140 CHAPTER NONCOMMUNICABLE DISEASES AND AGING

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7~4 Estimated annual mortality rates per 10,000 adults ages 60 and older in 2008.

Source: Data from The global burden of disease: 2004 update (April 2011 update). Geneva: WHO; 2011.

The number of years an individual adult lives without disability is a function of a lifetime of behaviors such as diet, physical activity, tobacco and alcohol use, and adherence to prescribed medical regimens, in addition to being influenced by personal characteristics like genetics and psycho- social factors. s Older adults also have a greater likelihood of maintaining a high quality of life when they have access to affordable preventive and therapeutic healthcare services, safe home and community environments, and strong family and social support.s

More than one-third of older men and women die of cardiovascular disease, most often from a heart attack or a stroke or complications related to these events. The relative proportion of heart disease and stroke varies somewhat between countries, but within countries this ratio tends to be similar for females and males 4

Just like every other organ in the body, the tissues that make up the heart require a constant supply of oxygenated blood. Atbem§derosh; occurs when the walls of the arteries that carry oxygen-rich blood from the heart to

7.2 Cardiovascular Diseases 141

80%

60%

40%

20%

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USA South Poland Brazil China India Kenya Sierra Korea Leone

DNon-CVD causes of death

l1li Other cardiovascular disease

!'Ill Stroke

l1li Ischemic heart disease

Figure 7-5 Proportion of deaths from cardiovascular disease (CVD) and other causes among adults ages 60 and older in 2008.

Source: Data from The global burden of disease: 2004 update (April 2011 update). Geneva: WHO; 2011.

the rest of the body, including to the heart muscle itself, thicken and harden. The diameter of those vessels consequently narrows, limiting the blood supply to the tissues fed by those arteries. When atherosclerosis occurs in the arteries that provide blood to the heart, a condition known as coronary artery disease, the blood flow to the heart may be reduced. Reduced blood supply (ischemia) can present as chest pain (angina), and more serious blockage of the arteries may lead to a heart attack (more formally called a myocardial infarction), which causes a portion of the heart muscle to die due to a lack of oxygen.

A stroke (also called a cerebrovascular accident, or CVA) may occur when a blockage of a blood vessel, often due to a blood clot, causes ischemia in the brain. (Strokes can also be caused by bleeding in the brain, but hemorrhagic strokes are less common than ischemic strokes.) Common symptoms of a stroke include weakness on one or both sides of the body, confusion, trouble speaking or understanding, vision disturbances, a loss of balance, and a severe headache. Untreated hypertension (usually defined as a blood pressure higher than 140190 mm Hg) is a major contributor to the risk of stroke, and also increases the likelihood of heart failure, kidney fail- ure, aneurysms (bulges in blood vessels, which may rupture), and blindness.

142 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

The most significant predictor of cardiovascular disease is increasing age. However, there are also many modifiable risk factors, including tobacco use, physical inactivity, obesity, an unhealthy diet, consumption of exces- sive amounts of alcohol, unmanaged diabetes, and an unhealthy blood lipid profile (such as having elevated cholesterol and triglycerides), in addition to hypertension. 6 Lower socioeconomic status is also associated with an increased risk for cardiovascular disease, in part because people with lower incomes have fewer resources for addressing modifiable risk factors. 6

7.3 CANCER

About one in six older adults worldwide dies of cancer.? Cancers (sometimes called neoplasms) occur when abnormal cells begin to repro- duce uncontrollably, often invading nearby tissues and spreading to other parts ofthe body. Normal cells are genetically stable, and if mutations or other types of damage cannot be repaired the cell will undergo a process called apoptosis or programmed cell death. Cancer cells, in contrast, are genetically unstable and undergo unlimited reproductive cycles. Additionally, cancer cells can stimulate angiogenesis, the formation of new blood vessels to nourish a tumor, and the cells can metastasize, breaking away from the primary site and forming new tumors in other parts of the body. (Benign, noncancerous tumors usually remain encap- sulated at their original site.)

It is a bit misleading to refer to cancer as though it is one disease because there are several hundred different types of cancer. Cancers are named for the part of the body where they originate and for the specific type of cell that has become cancerous. For example, carcinomas form in epithelial tissues, which usually line the inside or outside of the body, and sarcomas arise from connective tissues like bones or muscles. Cancers are also classified based on whether the cancer cells remain noninvasive and local, if they have spread to regional lymph nodes, or if they have spread to distant parts of the body.

The risk factors for cancer are specific to the type of cancer. For example, human papillomavirus (HPV) is an infection that specifically increases the risk of cervical cancer in women, occupational benzene exposure is associated with a significantly increased risk of leukemia, and sun expo- sure increases the likelihood of developing skin cancer. Advanced age is the most important risk factor for most types of cancer. Tobacco use, exces- sive alcohol consumption, physical inactivity, and an unhealthy diet are also

7.3 Cancer 143

risk factors for many types of cancer, and these are modifiable exposures. Inherited mutations are responsible for relatively few cases of cancer; most people diagnosed with cancer do not have a family history of that type of cancer. For many types of cancer, no major risk factors-modifiable or otherwise-have been identified.

Worldwide, the most commonly diagnosed cancers in men, from most common to less common, are cancers of the lung, prostate, colon/rectum (large intestine), stomach, and liver. The most common causes of cancer death for men are cancers of the lung, liver, stomach, colon/rectum, and esophagus. 8 For women worldwide, the most commonly diagnosed cancers are cancers of the breast, uterine cervix, colon/rectum, lung, and stomach. The most common causes of cancer death for women are cancers of the breast, lung, cervix, colon/rectum, and stomach. 8 However, there are impor- tant differences between countries and regions (l'able 8 For example, cervical cancer remains a leading cause of cancer death among women in low-income countries but is now fairly rare in high-income countries due to routine use of Pap smears for early detection of cancerous and precancer- ous lesions and also the use of the HPV vaccine, which prevents recipients from becoming infected with several of the most common strains of HPV that are associated with an increased risk of cervical cancer.

The proportion of people who live in high-income countries who develop cancer is much higher than the proportion in low- and middle- income countries (Figure 7<4j),9 pardy because cancer is more common in older adults and more people in high-income countries reach older ages. However, the population mortality rates from cancer are only a little higher in high-income countries 10 and because so many more peo- ple live in developing countries than in industrialized ones, the number of cancer deaths in low- and middle-income countries is considerably higher than the number of deaths in high-income countries (Figu:re 7-8)0 9 This means, for example, that although a person who lives in a more developed country is more likely to be diagnosed with lung cancer or breast cancer than a person who lives in a less developed country, the total number of deaths each from these cancers is higher in less developed regions. 11

Survival rates for those diagnosed with cancer also vary significantly between countries, with survival rates significantly lower in developing countries than in developed countries 12 People living in low- income countries are often not diagnosed until the cancer is at an advanced stage and the available treatment options are limited. If access to screening and diagnostic tests, which allow for detection of cancer at an earlier, more treatable stage, and access to advanced therapies like chemotherapeutic

-+>- Table 7-1 Most common cancer diagnoses and causes of cancer mortality. +>-

South Sierra n USA Korea Poland Brazil China India Kenya Leone

i:I: >- "Ii ...,

Most Commonly Prostate Stomach Lung Prostate Lung Lung Esophagus Prostate trJ :;c

Diagnosed -..l

Cancers in Men Lung Colorectum Prostate Lung Stomach Mouth Prostate Liver

Z Colorectum Lung Colorectum Stomach Liver Throat Stomach Lung 0

Z n

Most Common Lung Lung Lung Lung Lung Lung Esophagus Prostate 0 Causes of ~

Colorectum Liver Colorectum Prostate Liver Throat Prostate Liver ~ Cancer Death c::: in Men Z Prostate Stomach Stomach Stomach Stomach Mouth Stomach Lung ...... n

>- Most Commonly Breast Thyroid Breast Breast Breast Cervix Breast Cervix c:l t""' Diagnosed trJ

Cancers in Lung Breast Lung Cervix Lung Breast Cervix Breast C1 ...... Women

en Colorectum Colorectum Colorectum Colorectum Stomach Ovary Esophagus Liver trJ >-en

Most Common Lung Lung Lung Breast Lung Cervix Cervix Cervix trJ en Causes of >- Cancer Death in Breast Stomach Breast Cervix Stomach Breast Breast Breast Z t:I Women Colorectum Colorectum Colorectum Lung Liver Ovary Esophagus Liver >

C"l ......

Source: Data from Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v1.2: Cancer Incidence and Z C"l

Mortality Worldwide. Lyon: IARC; 2010.

7.3 Cancer 145

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o Less developed regions

Figure 7~6 Estimated age-standardized annual number of new (incident) cases of cancer per 100,000 people in 2008.

Source: Data from Feday J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010; 12:2893-2917.

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Figtme 7~7 Estimated age-standardized number of cancer deaths per 100,000 people in 2008.

Source: Data from Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010; 12:2893-2917.

146 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

600,000...------------------------,

500,000+-_f-----------------------1

400,000

300,000

200,000

100,000

iii More developed regions

III Less developed regions

Source: Data from Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010; 12:2893-2917.

100...-----------------------,

III United States

III More developed regions

III Less developed regions

Figure 7-9 Estimated age-adjusted 5-year cancer survival rate for selected cancers in 2002.

Source: Data from Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J CUn. 2005; 55:74-108.

7.4 Chronic Lung Disease 147

drugs, technology-enhanced surgical techniques, and radiology regimens were increased, many more people worldwide would survive their bouts with cancer.

Nearly lO% of older adults worldwide die of 4,13 COPD is characterized by

coughing, shortness of breath, wheezing, and tightness in the chest due to dam- age to airways (the bronchi and bronchioles) and the tiny air sacs (alveoli) in the lungs where gas exchange takes place. Progressive thickening and narrow- ing of the airways occurs because of inflammation and excess production of mucus that clogs breathing passages. This process causes chrordc A reduction in gas exchange occurs as the alveoli lose elasticity and become distended or destroyed, which reduces the surface area available for intake of oxygen and release of carbon dioxide. This process is called These symptoms are often accompanied by which makes the airways sensitive to exposures like air pollutants, cold air, and stress.

Although treatment can help manage some symptoms, the damage to the airways and lungs is not fully reversible with current therapies. Symptoms

200,-------------------------------------------~

160+-----------------------------

120+------------------------

80+-----------------------

40~~---------------

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

7-10 Estimated age-standardized chronic respiratory disease mortality rate per 100,000 people in 2008. Source: Data from Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

148 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

often worsen over time. Although not curable, COPD is often preventable. The most common risk factors besides age are exposure to tobacco smoke, indoor and outdoor air pollution, and industrial chemicals. 14

7.5 DIABETES

Insulin is a hormone produced by the pancreas that helps the body to maintain a relatively constant level of glucose (sugar) in the bloodstream so that cells have a relatively constant supply of energy. Type 1 diabetes (pre- viously called juvenile-onset diabetes or insulin-dependent diabetes) occurs when the body does not produce enough insulin. Type 2 diabetes (formerly known as adult-onset diabetes or non-insulin-dependent diabetes) is far more common and happens when the body stops responding appropriately to insulin even when the hormone is still being produced. The risk factors for type 2 diabetes include age plus obesity and related lifestyle character- istics, such as physical inactivity and an unhealthy diet. Signs of the initial onset of diabetes may include increased thirst and hunger, frequent urina- tion, unexplained weight loss, fatigue, and frequent slow-healing infections.

The goal of diabetes management is to keep blood sugar levels from becoming too high (hyperglycemia) or too low (hypoglycemia). People with type 1 diabetes require frequent insulin injections to maintain a safe blood sugar level. For those with type 2 diabetes, the disease can often be man- aged with weight loss, a careful diet, and sometimes also oral medications. Failure to carefully maintain blood sugar levels can, over the years, cause complications like blindness (from diabetic retinopathy), kidney failure, nerve damage (diabetic neuropathy), and foot ulcers leading to amputation.

The prevalence of diabetes is increasing in both lower- and higher- income countries, and will continue to do so in the coming decades as the proportion of adults who are obese increases (Figure 7_11).15 Diabetes and its complications, including an increased risk of cardiovascular death, are becoming major causes of premature death worldwide. 16

7.6 SENSORY IMPAIRMENT

More than 300 million people worldwide are blind or have low vision. I? Common causes of adult vision loss include cataracts, in which the lenses of the eyes become cloudy; glaucoma, which causes loss of peripheral vision due to elevated pressure within the eyeball; age-related macular degeneration, which causes loss of central vision; chronic diseases like

7.7 Disability 149

16%.---------------------------------------------------~

USA South Poland Brazil China India Kenya Sierra Korea Leone

7~H Estimated proportion of adults ages 20 to 79 with diabetes in 2010 and projected for 2030.

Source: Data from Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87:4-14.

diabetes; and infections. 18 Many of these cases of blindness could be pre- vented with advanced medical care, and many individuals with low vision could regain at least some of their sight with glasses to correct refractive errors (like myopia and astigmatism) or surgery to replace lenses damaged by cataracts. Those with untreatable or untreated visual impairments may experience reduced quality of life, mobility, and independence.

More than 250 million people worldwide are deaf or hard of hearing. 19 Age-related hearing loss (presbycusis) often makes it difficult for older adults to hear high frequencies. Hearing loss is also often noise induced, as high-intensity sounds damage the special surfaces (stereocilia) of cells in the ears that receive noise signals and transmit them to the brain.

Vision and hearing disorders are responsible for more than 10% of the disability experienced by adults age 60 and older.7

7.7 DISABILITY

Skeletal diseases such as arthritis and osteoporosis, muscle weakness, nervous system disorders such as Parkinson's disease (which causes tremors), intellectual or cognitive impairments (perhaps resulting from

150 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

a stroke or brain trauma), and sensory impairments that affect vision, hearing, and speech can all result in activity limitations and disability for older adults. A distinction is made between anatomical and physiologi- cal impairments and disabilities. Disability is both a health condition and a social context in which a person with impairment interacts with other people, institutions, and the environment (Figure 7-12).

One way of measuring disability is to ask how much functional impair- ment is caused by the physical or sensory impairment. Is the person with the impairment able to complete routine daily personal care functions such as bathing and dressing (Table 7-2)? Is the person independently able to manage his or her home by making meals, cleaning, and completing other essential tasks? Or does the person with the impairment require assistance from other people for the completion of daily activities? Does the condition cause extreme limitation in personal activities and participation in society, or relatively little limitation in these domains (Table 7-3)? Can the person with the condition fully participate in social events or is the person mar- ginalized because of his or her disability?

Figure 7-12 The relationship between impairments and disabilities (activity limitations and participation restrictions).

Table 7-2 Activities of daily living.

Activities of Daily Living (ADLs): Instrumental Activities of Daily Living (IADLs): Self-Care Independence

Dressing Shopping

Eating Housekeeping

Ambulating (mobility) Accounting (personal finances)

Toileting Food preparation

Hygiene Transportation

7.7 Disability 151

Table 7~'3 Domains of activity and participation from the International Classification of Functioning, Disability, and Health (ICF).

Domain

Learning and applying knowledge

General tasks and demands

Communication

Mobility

Self-care

Domestic life

Interpersonal interactions and relationships

Major life areas

Community, social, and civic life

Activities

Watching, listening, learning to read, learning to write, learning to calculate, solving problems

Undertaking a single task, undertaking multiple tasks

Receiving spoken messages, receiving nonverbal messages, speaking, producing nonverbal messages, conversation

Lifting and carrying objects, fine hand use (such as picking up objects or grasping them), walking, moving around using equipment (such as a wheelchair), using transportation

Washing oneself (such as washing hands, bathing, and using a towel), caring for body parts (by brushing teeth, shaving, and grooming), toileting, dressing, eating, drinking, looking after one's own health

Acquisition of goods and services (such as by shopping), preparation of meals (such as by cooking), doing housework (such as cleaning house, washing dishes, doing laundry, and ironing), assisting others

Basic interpersonal interactions, complex interpersonal interactions, relating to strangers, formal relationships, informal social relationships, family relationships, intimate relationships

Informal education, school education, higher education, remunerative employment, basic economic transactions, economic self-sufficiency

Community life, recreation and leisure, religion and spirituality, human rights, political life and citizenship

Note: The ICF is a series of guidelines for assessing disability. For example, the ICF has codes for indicating changes in body structure such as total absence, partial absence, additional part, aberrant dimensions, discontinuity, or deviating position.

Source: Information from International classification of functioning, disability, and health (ICF). Geneva: WHO; 2001.

152 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

A second consideration is the environment and resources available for the person with a physical impainnent. A person who uses a wheelchair may only have minor limitations in accessing buildings in South Korea, but may find it impossible to navigate the unpaved pathways of rural Kenya. An American with a visual impairment may have access to books through Braille editions, electronic magnifiers, and books on tape, but a similarly impaired person in Sierra Leone may not have access to any of these tools. Poverty also limits access to resources, and disabled people and their families are more likely to be poor than people without disabilities. Disabilities are expensive because there are direct costs related to treatment, the disabled person may be unable to work, and caregivers may have to limit their paid employment and home productivity or hire others to provide care. Disabled people may also have fewer opportunities to escape poverty because they are often denied access to education, employment, and public services. A safe physical environment (Table 7-4) and a strong social

Table 7-4 Environmental characteristics that relate to activities and participation.

Environment

Products and technology

Environmental Characteristics

Products for personal consumption (food, medicines), for personal use in daily living, for personal indoor and outdoor mobility and transportation, for communication; design, construction, and building materials of buildings for public use and buildings for private use

Natural environment and Climate, light, sound human-made changes to the environment

Support and relationships

Attitudes

Services, systems, and policies

Immediate family, friends, acquaintances, peers, colleagues, neighbors, community members, people in positions of authority, personal care providers and personal assistants, health care professionals

Individual attitudes of immediate family members, friends, personal care providers and personal assis- tants, healthcare professionals; societal attitudes; social norms, practices, and ideologies

Housing, communication, transportation, legal, social, health, education and training, labor and employment

Source: Information from International classification of functioning, disability, and health (ICF). Geneva: WHO; 2001.

7.8 Dementia 153

support system are key to preventing disability for older adults and for maximizing the activities and social participation of all who have impair- ments and disabilities.20

A third way to measure disability is based on the duration of the impair- ment. Is the condition permanent or short term? A person with a severe spinal cord injury will probably have life-long paralysis, but a broken bone will heal. Here, too, there are significant differences between high-income and low-income populations. Some conditions that are considered permanent disabilities in low-income regions are preventable or treatable in other parts of the world. Cataracts are the most common cause of blindness in older adults, but can be surgically corrected. Arthritis (swelling of the joints) may not be able to be cured, but the pain of arthritis can be managed with medications. Infections like onchocerciasis (river blindness) and trachoma that can cause blindness can be prevented or treated early so that they do not progress to an advanced stage.

Adults and children of all ages who have physical impairments can benefit from access to appropriate physical therapy, occupational therapy, speech therapy, and other types of rehabilitation. For example, people who have had a stroke can re-learn language and self-care skills, especially if they receive therapy within days after the stroke. Access to assistive medical devices, such as prosthetics for people with a missing arm or leg, orthotics and braces for people with various types of musculoskeletal disorders, hearing aids, and glasses, is also crucial. Most importantly, people with physical impairments and disabilities benefit from being included to the fullest extent possible in the activities of their families and communities.

Delrillentia is a term used to describe a gradual decline in cognitive function that usually presents as severe memory loss combined with other symptoms such as impaired judgment, personality changes, inappropriate behavior, difficulty with language, and/or confusion. The most common type of dementia is Alzheimer's disease, which is associated with anatomical changes in the brain, including the formation of beta-amyloid plaques and neurofibrillary tangles. Dementia may limit the ability of an older adult to live independently and may cause significant stress for those caring for a loved one with the disorder.

The risk of dementia increases significantly with age. About 5% to 10% of the disability in adults ages 60 and older is attributable to dementia, with

154 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

much higher rates for the oldest adults.7 More than 25 million adults world- wide currently have dementia, and that count will increase significantly in the coming decades.21

7.9 SCREENING AND EARLY DETECTION

Screening is a type of secondary prevention in which an entire well- defined group of people is encouraged to be tested for a disease based on evidence that members of the population are at risk for the disease and that early intervention improves health outcomes. The goal of screening pro- grams is to diagnose cases of the disease at an early, more treatable stage and/or to identify people who have risk factors for the disease so that they can take preventive measures (Figure 7-13).

A good screening test will yield a high proportion of correct results (true positives and true negatives) and a very low proportion of erroneous results (false positives and false negatives). In other words, a good screening test should have a high sensitivity and a high specificity (Figure 7-14). The sensitivity of a test is the proportion of people who truly have the disease who test positive for the disease. The specificity of a test is the propor- tion of people who are truly free of the disease who test negative for it. A test is usually considered to be a relatively reliable tool, one that makes a correct diagnosis most of the time, if it has a sensitivity of at least 95%

Timeline Without Screening: Diagnosis

Biological onset of disease

Disease could Symptoms Medical made and be detected of disease care is treatment

through testing develop sought begins

Time-....... ---~II-----___ .... I --~II----....... I-+. ( ;

Timeline with Screening:

Time period when screening will detect disease early so therapy can begin at an

earlier stage of disease

Biological Disease could Diagnosis made and treatment onset of be detected

disease through testing begins Time ____ I ________ I __________ I __________________________ ~.

Figure 7-13 Timeline for the natural history of disease.

Correct Results:

7.9 Screening and Early Detection 155

Analysis for Screening

Test Result

True Disease Status +

Incorrect Results: True Positives = a True Negatives = d

False Positives = b False Negatives = c

Sensitivity of the Test = ~ a+c

Specificity of the Test = _d_ b+d

Positive Predictive Value (PPV) = ~ a+b

Negative Predictive Value (NPV) = ~ c+ d

Figure 7-14 Validity of screening tests.

and a specificity of at least 80%. Ideally both of these values will exceed 99%. The predictive value (PPV) is the proportion of people who test positive for the disease who truly have disease, and the pJredidive value is the propOltion of people who test negative for the disease who truly do not have disease. These values are based in part on the prevalence of the disease in the population being tested. A test will have a higher PPV in a population with a high prevalence of disease than in one with a lower prevalence rate.

For many screening tests there is not one obvious cut-off point to dis- tinguish between a person with disease and a person without disease. For example, hypertension could be defined as having a systolic blood pressure (SBP) greater than 160 mm Hg, or it could be defined more expansively as having an SBP greater than 140 nun Hg. Using a cut-off of 140 mm Hg wOllld result in a much higher prevalence of hypertension than using a cut- off of 160 mm Hg. The people who design and implement screening tests do their best to determine the level at which the risk of disease is sufficient to declare that the person should be classified as having the condition. For some diseases, especially those with no treatment or treatment that is

156 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

Table 7-5 Questions to ask before starting a screening program.

Is the disease life threatening?

Is the disease common in the target population?

Is there an early asymptomatic stage of the disease that could be detected through screening?

Is the test for early disease valid? (Does it have high sensitivity and high specificity?)

Is the test acceptable to the target population?

Is there an acceptable treatment for individuals found to have the disease?

Are facilities for further testing and for treatment available to the target population?

expensive and potentially harmful, it is better to have a high threshold for declaring that a person has the condition. For others it is better to have a low threshold, especially when early intervention can prevent serious complica- tions, as is the case for hypertension and diabetes.

Decisions about whether to implement a screening program and which pop- ulation subgroups to target are made by health professionals, policymakers, and communities after considering the most important local health conditions. Diseases that are part of screening programs are usually severe, relatively common, and treatable. Screening for these types of conditions is considered to be a cost-effective way to diagnose people in the early, often asymptomatic stages of disease when treatment is easier and cheaper (Table 7-5). In devel- oped countries, common types of screening tests include mole checks for skin cancer, Pap smears for cervical cancer, mammograms for early detection of breast cancer or precancerous lesions, digital rectal exams for prostate cancer, vision screening (including pressure tests for glaucoma), routine blood tests (for early detection of anemia, high cholesterol, high blood sugar, or other abnormalities), and routine blood pressure checks. Screening in low-income countries is more often geared at children and pregnant women, who are regularly weighed and examined, but adults in these areas would also benefit from improved access to routine screening for chronic diseases.

7.10 PLANNING FOR AGING POPULATIONS

A population pyramid displays the number of males and females by age group in a population. Low-income countries usually have a population pyramid with a wide base (many children) that gradually narrows in older

7.10 Planning for Aging Populations 157

age groups 7~15). These countries are often concerned about population growth and are taking measures to encourage decreased fertility rates. High-income countries often have low fertility rates that make the population "pyramid" look more like a cube Some of these countries with narrow bases (few children), especially in Europe,

% of the Population

Figul"e 7~15 Population pyramid for Kenya in 2009.

Source: Data from World development indicators database. Washington DC: World Bank.

% of the Population

Figure ',L16 Population pyramid for the United States in 2009.

Source: Data from World development indicators database. Washington DC: World Bank.

158 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

Table 7-6 Aging indicators in 2010.

South Sierra Country USA Korea Poland Brazil China India Kenya Leone

Aging Index 66 71 92 27 43 17 6 4

Dependency 49 37 39 48 39 55 81 82 Ratio

Elderly 5 7 5 10 9 13 21 29 Support Ratio

Source: Data from Hughes BB, Kuhn R, Peterson CM, Rothman OS, Sol6rzano JR. Improving global health forecasting the next 50 years. Patterns of Potential Human Progress Series, Volume 3. Boulder CO: Paradigm Publishers; 2011.

face a shrinking population size and are concerned about who will care for the aging population as the ratio of older adults to working-age adults increases.

The data from these pyramids can be used to calculate a variety of indicators of population aging (Table 7-6). The aging index is usually calculated as the number of people age 65 or older for every 100 children under the age of 15. A higher aging index indicates a more aged popula- tion. Social support ratios like the dependency ratio indicate the number of dependent children and older people for every person of working age (often defined as people ages 15 through 64). The elderly support ratio is usually defined as the number of people ages 15 through 64 for every 100 people ages 65 and older in a population. Populations with relatively few working age adults for each older adult are more aged populations. (Because many older people remain active and economically independent, alternate measurements may include only dependent older people.) These population characteristics help social service providers and policymakers to understand the current needs of the populations they serve and to create plans that will help their populations prepare for the future.

Many older people contribute to families and communities by taking care of their grandchildren, providing training and guidance for younger employees, connecting younger generations to their cultural heritage, and sharing wisdom gained from decades of life experience. However, most older adults will eventually develop chronic health conditions that limit their independence. Staying with family when assistance with activities of daily living becomes necessary is often the preference of both older

7.11 Discussion Questions 159

people and their families. In most of the world, care of the elderly is provided by spouses, children, and other family members, and institu- tionalization of older people is uncommon. But decreasing fertility rates mean that in many parts of the world there are fewer young people to care for older family members, and the increasing proportion of women who work outside the home also limits the number of people available to provide in-home care. Thus, an increasing proportion of older adults in a population puts stress on healthcare systems as well as on caregivers at home.

Few countries are prepared to care for a rapidly increasing number of older people with chronic illnesses and disabilities. In high-income countries, the growing proportion of older adults is already creating significant challenges for older adults, caregivers, health systems, and national pension systems. The national pension programs of many indus- trialized countries, especially in Europe, are on the verge of collapse because there are not enough young workers paying in to the programs to support retirees sufficiently. The retirement age is being increased and benefits are being cut. In developing countries where retirement accounts and pension plans are not the norm, aging is also expected to become a major social issue. The migration of young rural people to cities means that adult children often live far from their aging parents and cannot provide daily care, and few families have the ability to hire additional caregivers or nursing assistants. The ability to support older persons will become a significant concern in Latin America and much of Asia in the coming decades. All countries need to begin planning for the care of aging

1 · 22 popu atlOns.

1. What have you gained from interactions with older adults? What have you contributed to enriching the lives of older adults?

2. How many years do you expect to live? What factors contribute to your estimation of your life expectancy?

3. What do you think will be the cause of your death? Why do you think that?

4. What are steps you can take now that will help you to live a long, healthy life? What are steps you can take now to minimize the likelihood of various types of chronic diseases and disabilities when you become an older adult?

160 CHAPTER 7 NONCOMMUNICABLE DISEASES AND AGING

5. What are some examples of health screening tests recommended for people of your age and sex? Do you adhere to these recommendations? Why or why not?

6. How have the older members of your family been cared for as they aged? Have they moved into an assisted living facility, moved in with their children or grandchildren, or made alternate arrangements? How did family and financial considerations play into these decisions?

7. What do you think your preferences for care will be when you are older? What factors might prevent you from receiving this type of care?

REFERENCES

1. World development indicators database. Washington DC: World Bank. 2. Hughes BB, Kuhn R, Peterson CM, Rothman DS, Solorzano JR. Improving global

health forecasting the next 50 years. Patterns of Potential Human Progress Series, Volume 3. Boulder CO: Paradigm Publishers; 2011.

3. United Nations Department of Economic and Social Affairs. World population ageing 2009. New York: UN; 2010.

4. The global burden of disease: 2004 update (April 2011 update). Geneva: WHO; 2011. 5. Active ageing: a policy framework. Geneva: WHO; 2002. 6. Mackay J, Mensah GA. Atlas of heart disease and stroke. Geneva: WHO and

U.S. CDC; 2004. 7. The global burden of disease: 2004 update. Geneva: WHO; 2008. 8. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v1.2:

Cancer Incidence and Mortality Worldwide. Lyon: IARC; 2010. 9. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide

burden of cancer in 2008: GLOBOCAN 2008.Int J Cancer. 2010;12:2893-2917. 10. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics.

CA Cancer J CZin. 2011 ;61 :69-90. 11. Kamangar F, Dores GM, Anderson WF. Patterns of cancer incidence, mortality, and

prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world. J Clin Oncol. 2006;24:2137-2150.

12. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005; 55:74-108.

13. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011. 14. Mannino DM, Buist AS. Global burden of COPD: risk factors, prevalence, and future

trends. Lancet. 2007:370:765-773. 15. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for

2010 and 2030. Diabetes Res Clin Pract. 2010;87:4-14. 16. van Dieren S, Beulens JW, van der Schouw YT, Grobbee DE, Neal B. The global

burden of diabetes and its complications: an emerging pandemic. Eur J Cardiovasc Prev Rehabil. 201O;17(supp1):S3-S8.

17. Resnikofff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. 2008;86:63-70.

References 161

18. State of the world's sight: VISION 2020: the right to sight 1999-2005. Geneva: WHO; 2005.

19. Mathers C, Smith A, Concha M. Global burden of hearing loss in the year 2000. Global Burden of Disease 2000 Study Working Paper. Geneva: WHO; 2003.

20. International classification of functioning, disability, and health (ICF). Geneva: WHO; 2001.

21. Ferri CP, Prince M, Brayne C, et al.; Alzheimer's Disease International. Global preva- lence of dementia: a Delphi consensus study. Lancet. 2005;366:2112-2117.

22. Why population aging matters: a global perspective. Washington DC: U.S. Department of State and U.S. National Institute on Aging; 2007.

AND

Humans have long recognized the environment's role in disease etiology. Nearly 2500 years ago, Hippocrates, a Greek physician, catalogued envi- ronmental, dietary, behavioral, and constitutional conditions linked to health, and wrote that "from these things we must proceed to investigate everything else."! The germ of disease did not become widely accepted until the late 1800s, but for many centuries before microscopes allowed people to see pathogens, communities recognized that some illnesses were linked to environmental exposures, and they took care to dispose of human waste, to protect water sources, and to bury the carcasses of diseased animals.

Public health efforts in the 19th century focused primarily on envi- ronmental sanitation, with special attention aimed at reducing epidemics thought to be associated with urban crowding and its associated grime. 2

For most of the 1800s, the prevailing theory of disease causation in Western countries was that epidemics were spontaneously generated from "miasma atmospheres" that occurred in places with poor sanitation and the accompanying foul odors of poorly managed waste. 3 For example, during serious cholera outbreaks in England in the mid-1800s, investigators (led by William Farr, a respected health statistician) found a higher infection rate in places of low altitude, especially places near marshes that had

163

164 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

an abundance of foul-smeIHng gases, and the mi~§ma theory of disease blamed the spread of cholera on contact with those offensive gases.4 This was a reasonable conclusion because the people who lived in the gassy, marshy areas were the same people who drank the bacterium-infected water that was the true cause of the outbreak (as determined by John Snow, one of the founders of modern epidemiology, who traced the source of one outbreak in London back to one very specific source, the Broad Street water pump).

By the middle of the 20th century, most medical scientists had shifted their efforts from the identification of social and environmental risk factors for disease to the identification of specific infectious agents and genes. 5 But even with the emphasis on immunology and genetics, one of the biggest public health breakthroughs in the 20th century was a series of studies published in the 1950s that confirmed that cigarette smoking was a major cause of lung cancer, emphysema, and cardiovascular disease. 6 Later studies indicated that exposure to secondhand smoke was an additional risk factor for lung disease. 7

Today's scientists, health professionals, and health consumers agree that there are many social and behavioral, environmental, and biological contributors to disease. Good hygiene (like frequent handwashing) and the avoidance of known environmental hazards are important for preventing a host of diseases, and environmental health continues to playa very impor- tant role in public health and safety.

Modern environmental health scientists assess the impact of people on their environment and the impact of the environment on human health, specializing in areas like air quality, food protection, radiation protec- tion, solid waste management, hazardous waste management, water quality, noise control, environmental management of recreational areas, housing quality, and animal and vector (insect) control. A major goal of environ- mental health is to understand the conditions that contribute to disease so that diseases can be prevented. For example, environmental health scien- tists may start with questions like "What are the health effects smog (or contaminated water, acid rain, the thinning of the ozone layer, or the spraying of pesticides on crops)?" and then use the answers they find to promote changes in environmental health laws that regulate air quality, water quality, the disposal of waste, or chemical use.

Environmental health looks at all aspects of the physical environment- where people live and work and the materials used to construct these buildings, what people eat and where that food comes from, the source and quality of the drinking water, the of the air that is breathed, and

8.1 Environmental and Occupational Health 165

the length and route of workers' commutes. A great deal of environmental research focuses on identifying environmental risk factors for cancer and for chronic diseases like asthma and arthritis. This research has shown, for example, that exposure to ultraviolet light from the sun and tanning beds contributes to the development of skin cancer and that air pollutants con- tribute to the development of lung cancer.

The physical environment also impacts health behavior. A recent study of global cancer mortality estimated that 35% of cancer deaths were due to just nine lifestyle and environmental factors: overweight and obesity, low fruit and vegetable intake, physical inactivity, smok- ing, alcohol use, unsafe sex, urban air pollution, indoor smoke from household use of solid fuels, and contaminated injections in healthcare settings. 8 Some of these factors, like air pollution and indoor smoke, are clearly environmental. Others are related both to the environment and to social, behavioral, and economic factors. Fruit and vegetable intake is easier for people who live where they can grow their own produce and harder for people who live in cities where produce is expensive and may not be fresh. A person who lives in an unsafe neighborhood may feel threatened when outdoors and may not have the space to be active indoors, so physical activity is curtailed.

Some environmental health researchers focus on issues related to geography, geology, and climate. Health risks are often tied to the local climate, whether the location is desert, tropical, artic, or something more moderate. Types of vegetation and animals that are native to particular climates, weather patterns and temperature, altitude, geologic formations (like volcanoes and earthquake fault lines), soil types, and other factors can influence risk for both communicable and noncommunicable diseases. For example, older people who live at high altitudes and have had long-term exposure to ultraviolet light, wind, and dust are at risk for developing a pterygium, a triangular growth that starts on the white part of the eye but may eventually cover the pupil and cause blindness. And malaria is a risk only for people who live in a climate that can support the life cycle of the mosquitoes that spread the malaria parasites.

Most environmental health experts focus on aspects of health related to the home, workplace, or community. Occupational and industrial health specialists spend their time assessing and mitigating workplace hazards, which may mean measuring noise levels in a factory and issuing appropri- ate ear protection or making sure that people who spend their days in front of a computer have ergonomically designed chairs and are taking steps to minimize repetitive motion injuries. Other occupational and industrial

166 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

health specialists focus on potential hazards in the home environment, such as lead paint, radon, and mold; they might also assess community risks, such as garbage dumps and runoff into waterways.

802 THE HOME ENVIRONMENT

Environmental health is also concerned with the health and safety of the home environment Most buildings contain potential health hazards. Construction materials may be harmful, such as paint that contains lead (which can cause mental impairment in children who ingest paint chips) or insulation that con- tains asbestos (which can increase the risk of some types of lung cancer). Electrical wiring installed incorrectly may lead to the risk of electrocution. Windows without screens may let insects in, and poorly insulated and sealed walls and ceilings may not protect residents from cold and precipitation. Some residences may have high levels of radon, the second most common cause of lung cancer after tobacco, or may be infested with cockroaches, tennites, or rats. There may also be hazardous chemicals stored in kitchens, bathrooms, garages, and sheds, and these substances, such as cleaning agents, fertilizers, and motor oil, may create new dangers when they are stored or disposed of improperly.

All of these conditions may be potentially hazardous, but in some ways it is a luxury to be able to worry about these household threats. For many people in the world, the most important household considerations are shelter, water, sanitation, and fuel for heat and cooking. A shelter is a dwell- ing that provides at least some protection from the sun, rain, wind, and other elements. At the outskirts of large cities in low-income parts of the world, large shantytowns built from cardboard may spring up overnight to accom- modate rural-to-urban migrants. These may eventually be replaced with shacks built from blocks or bricks with a tin or asbestos roof, or replaced with sturdier houses constructed from cement, but once a minimal sort of protection is built the focus of the new resident is on finding a source of safe water for drinking and washing, a place away from the home that can be used to dispose of human waste, and a source of fuel for cooking.

Contaminated water, poor sanitation and hygiene, and inadequate man- agement of human and animal waste are all associated with an increased risk of diarrheal diseases and other infections. Air pollution, including the indoor air pollution caused by cooking over open fires, is associated with acute respiratory infections, chronic respiratory diseases, and some types of cardiovascular disease and cancer. Increasing access to healthy housing, clean water supplies, sanitation facilities, and clean air and fuel improves the health of families and communities.

8.3 Drinking Water 167

DRINKING

Everyone needs access to an adequate supply of clean water. In addition to water for drinking and cooking, each person also needs water for hygiene (handwashing and bathing) and cleaning (washing clothes, cleaning cook- ing pots, and cleaning homes). Increased access to water is associated with improved health, as the incidence of diarrheal and other infectious diseases decreases when more water is available for hygiene. Another important household benefit of gaining access to an improved water source is that it saves a lot of time. When water sources are far from the home, women and children may spend several hours each day walking to a water source, waiting for their turn to fill a container, and walking home. The time saved could be used for other activities, which may be social, educational, or health oriented (such as cooking nutritious food, sleeping, or cleaning). There are at least five key aspects of water access: quality, quantity, prox- imity, reliability, and cost.

Quality: Water must be clean enough to drink safely. It needs to be free of bacteria, viruses, and parasites that can cause infection, and must also be free of harmful chemicals and sediments. The water should not appear cloudy, dirty, or strangely colored, so that it does not cause problems with cooking (such as giving food a strange flavor, color, or texture) or washing. 9

Ideally, the water should be drawn from a protected source, which means that people should not wash clothes or bathe near where drinking water is collected, and animals, sewage, and garbage should be kept away from the water source. lists examples of improved and unimproved drinking water sources. 10

T1llb~e 3~o·1 Examples of improved and unimproved drinking water sources.

Improved Drinking Water Sources

.. Piped water into home or yard

" Public tap or standpipe

" Tube well or borehole

.. Protected dug well

.. Protected spring

" Rainwater collection

Unimproved Drinking Water Sources

.. Unprotected well

" Unprotected spring

" Surface water (water from a river, dam, lake, pond, stream, canal, or irrigation channel)

" Water from vendors (like tanker trucks or carts with a small tank or drum)

to Some bottled water

Source: Information from Progress on sanitation and drinking water: 2010 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 20-10.

168 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

Quantity: Enough water must be available so people can stay hydrated and clean. The average minimum amount of water needed by one person each day for survival purposes is about 15 to 20 liters (about 4 to 5 gallons): about 1 to 3 liters for drinking, 2 to 3 liters for food preparation and cleanup, 6 to 7 liters for personal cleanliness, and 4 to 6 Hters for laundry. 11 Table 8-2 summarizes the levels of water access worldwide and shows that a minimum of 50 liters (13 gallons) of water per person per day is recommended for healthy living. About 1 in 7 people worldwide are in the "No access" category of the table. 12 The average American uses about 100 gallons daily for domestic purposes. 13

Proximity: To be considered accessible, the water source must be close enough to the home so that distance does not prevent people from accessing the water they need. At best, water is piped directly to an indi- vidual house. However, many improved water systems instead simply bring clean water closer to homes via a public community standpost (standpipe), borehole, or protected (and lined) dug well. In some places it is possible for households to supplement their water access by collect- ing and storing rainwater for drinking and domestic use. Ideally, a safe drinking water source should be within 1 kilometer (about 0.6 miles) of a home. 14

Reliability: The water source must be available and functioning all the time, or the household must have access to adequate water storage and water treatment methods such as filtering, boiling, and using chemicals like chlorine. One way to ensure that water systems can be maintained is to use applt'op:riate that is simple enough that broken equipment, like water pumps, can be repaired by local residents cheaply and quickly.

Cost: Water must be affordable enough that people have access to at least the minimum amount of water necessary for healthy living. This does not mean that water must be free. Households that use a community water system may be asked to pay a reasonable fee for use so that the system can be maintained. These fees also promote water conservation if they are tied to the amount of water drawn from the pump by a household. In most cases, community water fees are minimal and are recognized as essential for keeping the water system running. However, when public water sup- plies are not available and exorbitant prices are charged for bottled water, the cost of water severely limits access to it.

Access to water is a requirement for life, so water access is a sig- nificant concern for the many people in Africa and the Middle East and parts of Asia and Latin America who have limited access to an improved water source 10 especially those in rural areas

T",blE, 8~",2 Water service level (quantity, proximity, and quality) and health effects.

Service Level

No access

Basic access

Quantity (per person per day)

May be less than 5 liters

About 20 liters

Intermediate About 50 liters access

Optimal access

About 100 liters

Proximity

More than 1 km or 30 minutes round trip

Between 100 and 1000 meters or 5 to 30 minutes round trip

Water delivered through one tap that is within 100 meters or 5 minutes round trip

Continuous supply through multiple taps

Drinking Needs Met?

Neither quantity nor quality ensured

Quantity ensured but quality not ensured

Quantity and quality usually assured

Quantity and quality ensured

Hygiene Needs Met?

No because only avail- able at source

Yes for hand washing and food hygiene; no for laundry and bathing

Yes

Source: Data from Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003.

Level of Health Concern

Very high

High

Low

Very low

yo v,.,

tJ "'j ~.

"'"' ~. CfQ

~ ~ "'j

I-' 0\ \0

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<50%

50%-74.9%

75%-94.9%

95%-98.9%

Proportion of the total population with access to an improved water source in 2008.

, .. ' '!"

~'»,

Source: Data from Progress on sanitation and drinking water: 2010 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2010.

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100

8.3 Drinking Water 171

USA South Poland Brazil China India Kenya Sierra Korea Leone

ill! Urban

1m Rural

Ii Total

8-2 Proportion of the rural and urban populations with access to an improved drinking water source in 2010.

Source: Data from Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2012.

12 In most of North America and Europe, both urban and rural households have access to tap water. In many other world regions, however, less than 90% of the urban population and less than 40% of the rural population has access to an improved water source, even though this proportion has increased significantly in recent decades

8~3).12

Only 2.5% of the world's water is freshwater rather than saltwater, and two-thirds of that freshwater is in glaciers. The main sources of freshwater for human use are rainwater, surface water (such as water from streams and rivers), and ground water (which is accessed by drilling wells). About 70% of freshwater used every year is put toward agricultural uses such as irrigation and livestock production, 15 and there are increasing demands for agricultural, industrial, and domestic water use as the world population grows. These are exacerbated when surface water becomes contaminated by agricultural runoff, human waste, and other pollutants, and when ground water becomes depleted and causes rivers, wetlands, and lakes that depend on the ground water to dry out. Water scarcity is becoming a major concern in many parts of the world, especially for small island nations and for the desert countries of the Middle East and North Africa

172 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

100

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

l1li1990

til 2000

l1li2010

Figure 8-3 Proportion of the population with access to an improved drinking water source by decade between 1990 and 2010.

Source: Data from Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2012.

where internal freshwater resources are extremely limited. Countries with less than 200 cubic meters of renewable freshwater resources (internal surface water plus groundwater fed by rainfall in that country) per person face ongoing challenges (Table 8_3).15 As the demand for water increases, everyone needs to be concerned about the availability of freshwater resources.

8.4 SANITATION

Sanitation is the disposal of human excreta. There are several types of sanitation facilities that can be used for safe waste disposal (Table 8_4).12 One of the most basic sanitation systems is a simple pit latrine, which is a hole in the ground covered by an outhouse or encircled by a privacy blind. In many communities, ownership of a latrine is a sign of pres- tige, besides providing safety, cleanliness, comfort, privacy, and protec- tion from dangers at night and from snakes. A slightly more advanced ventilation-improved pit (or VIP) latrine vents fumes away from the outhouse and keeps flies out of it. Pour-flush systems require some water for washing away the waste. Septic tanks and sewer connections are

8.4 Sanitation 173

Table 8~3 Internal freshwater resources per person for countries with less than 200 m3 of renewable freshwater resources per capita and for featured countries in 2007.

Freshwater Resources per Capita

Country/Territory Region/Type (cubic meters)

Kuwait Middle East 0

Bahrain Middle East 5

Egypt North Africa 22

United Arab Emirates Middle East 34

Qatar Middle East 49

The Bahamas Small Island Nation 60

Yemen Middle East 94

Libya North Africa 97

Saudi Arabia Middle East 99

Maldives Small Island Nation 100

Israel Middle East 104

Jordan Middle East 120

Malta Small Island Nation 123

Mauritania North Africa 127

Singapore Small Island Nation 131 ------~. ---~--.-.-----.-----,--~-.-----

Kenya East Africa 548

India South Asia i 134

South Korea East Asia 1338

Poland Europe 1406

China East Asia 2134

USA North America 9344

Sierra Leone West Africa 29518

Brazil South America 48498

Source: Data from Little green data book 2011. Washington DC: World Bank; 2011.

174 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

Table B~4 Examples of improved and unimproved sanitation facilities.

Improved Sanitation Facilities

., Connection to a public sewer system

'" Connection to a septic system

" Pour-flush latrine

" Ventilated-improved pit (VIP) latrine

" Composting toilet

" Simple pit latrine

Unimproved Sanitation Facilities

.. Open defecation in a field, street, body of water, or other place

@ Bucket or bag

" Open pit latrine

" Flush or pour-flush toilet that drains to the street, yard, an open sewer, a ditch, a drainage way, or another location

.. Public or shared latrine

Source: Information from Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2012.

more advanced sanitation technologies. Advanced sanitation facilities are common in North America and Europe, but rare in many other regions

'" ") 12 (l~"t .

About half of the people who live in developing countries do not have access to even the simplest improved sanitation facility, such as a pit 1 · d . ,,-. ~o 12 R 1 'd atnne, an must practIce ope~l nelecanon ura resl ents may be able to go to a defecation site away from their living areas. Urban residents without access to a latrine often have no choice but to defecate on the street or into a bag that is thrown at the side of the street (a waste disposal method that is sometimes called a "flying toilet"). A desire for privacy means that many people, especially women, wait until dark to def- ecate, even though it is often dangerous for them to be out at night.

People who do not have an improved sanitation system are at increased risk for infectious diseases that are spread through contact with feces. The factors that contribute to diarrheal diseases have sometimes been described using the "six Fs": feces, fields, fluid, fingers, food, and flies. 16 Whenfeces are not properly disposed of, they can contaminate fields (soil) andfiuids (bodies of water). The fecal matter can then get onto hands, especially the hands of young children who frequently touch the ground, andfingers transport the fecal matter to food if hands are not washed before preparing food or before eating. Flies can also spread feces to food and water, and flies thrive where fecal matter is in the open. The risk of diarrheal disease increases when there is not enoughfiuid (water) to wash hands often.

The presence of feces near homes significantly increases the risk of bacterial, viral, and protozoal diarrheal diseases and helminthic (worm)

......

<50%

50%-74.9%

75%-94.9%

.,)g.

8~4 Proportion of the total population with access to improved sanitation in 2008.

Source: Data from Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2012.

00 ~

~ ~

~r "'-(S. ~

I-' --.l U1

176 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

100

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

• Urban

!IIi Rural

• Total

Figure 8-5 Proportion of the rural and urban population with access to an improved sanitation facility in 2010.

Source: Data from Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2012.

infections. Intestinal worm infections can be treated through the periodic distribution of de-worming medicines to school-age children and other at-risk population groups, but improved sanitation is a necessity for preventing new infections and reinfections. The best programs for reducing diarrhea and parasitism combine improved water and sanitation systems with health education to promote frequent handwashing and consistent use of latrines instead of open defecation. 17 Improved sanitation facilities, which are becoming more common around the world (Figure 8_6),12 must provide privacy, safety, and comfort, and must be kept clean. 16

8.5 FUEL AND INDOOR AIR QUALITY

Energy is necessary for at least three important purposes: cooking food and boiling water for safe consumption, providing a source of heat when outdoor temperatures are low, and providing a source of light at night. More than 20% of the world's people do not have electricity in their homes (Figure 8_7).18,19 Households without electricity usually rely on solid fuels (like wood, charcoal, coal, dung, and crop waste) for most of their energy needs. These may be supplemented by the use of candles and kerosene lamps for light.

8.5 Fuel and Indoor Air Quality 177

100

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

1!ll1990 III 2000

LJ 2010

3-6 Proportion of the population with access to an improved sanitation facility by decade between 1990 and 2010.

Source: Data from Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint Monitoring Programme for Water Supply and Sanitation; 2012.

100

o USA South Poland BraZil China India Kenya Sierra

Korea Leone

8-·7 Proportion of the rural and urban population with access to electricity in 2008.

Source: Data from World energy outlook 2010. New York: International Energy

II! Urban

LJ Rural

III Total

Agency (IEA); 2010; and Legros G, Havet I, Bruce N, Bonjour S. The energy access situation in developing countries: a review focusing on the least developed countries and sub-Saharan Africa. New York: UNDP and WHO; 2009.

178 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

All fuels that are burned for energy release air pollutants, including the fuels that provide energy for electricity. (Worldwide, coal is the most com- monly used source of fuel for electricity. IS) But solid fuels used in homes are particularly unhealthy because they are usually burned in open fires or in simple stoves that release most of the smoke from burning into the home. The pollutants in smoke from burning solid fuels include carbon monoxide, sulfur oxides, nitrogen oxides, aldehydes, and polyaromatic compounds.2o

These chemicals can cause lung disease by triggering inflammation, damag- ing the cells that line the respiratory tract, and impairing immune response. The smoke also contains particulate matter that can get deep into the lungs. Indoor air pollution is responsible for about 1.5 million deaths worldwide every yearI ,22 because it increases the risk of pneumonia and other respiratory diseases in children and increases the risk of chronic obstructive pulmonary disorder (COPD) and lung cancer in adults.23 The risks associated with indoor air pollution levels are particularly high for women and young children who spend several hours a day near fires while cooking.

Use of solid fuels can have other negative health effects. Children are at risk for burns from falling into open fires or knocking over pots of boil- ing water. Women and children often spend hours each week collecting sticks and brush to use as fuel, and they are susceptible to injuries related to carrying heavy loads over uneven and uncleared terrain. As sources of biomass close to the home are used up, they must travel further distances to find fuel. There are also environmental consequences: burning of solid fuels contributes to outdoor air pollution, and the demand for wood and charcoal contributes to deforestation.

There are several ways that people without electricity can reduce their exposure to indoor air pollution. 24 One is to use improved cooking devices such as those that have flues to divert pollutants out of the home and those that use alternative energy sources (like solar panels) that create less smoke. A second is to increase ventilation or move the kitchen to the outside of the home. (Obviously, relocating the kitchen does not help minimize the cook's exposure if the outside cooking area does not have a good ventilation system.) A third is to change behaviors, like taking care to keep children away from smoke and using pot lids to conserve heat.

For those who are able to access electricity, there are additional health benefits besides cleaner indoor air. For example, refrigeration allows for safer food storage and the use of a radio or television allows for health and safety messages such as advertisements for immunization campaigns, information about handwashing and other disease prevention techniques, and alerts about potential natural disasters such as oncoming

8.6 The Work Environment 179

hurricanes to be quickly received. Ideally, electricity can be produced by renewable sources that minimize air pollution and other types of environmental damage.

8.6 TlIE WORK ENVIRONMENT

Occupational health was one of the first public health specialty fields. 25

In 1713, Bernardino Ramazzini published Diseases of Workers, a book that detailed the environmental hazards encountered in 52 occupations, listing poisoning, respiratory diseases, problems related to prolonged postures and repetitive tasks, and psychological stress as some of many on-the-job threats to health. In 1753, James Lind published the results of an expeliment that sup- ported the hypothesis that sailors could prevent scurvy if they carned citrus fruit with them on long journeys?6 (After this discovery, sailors were sometimes called "limeys" for the citrus fruit carried on ships.) In 1775, Percivall Pott identified chimney soot as the cause of elevated rates of scrotal cancer in chim- ney sweeps.27 The coal tar in chimneys is carcinogenic, and because sweeps rarely bathed or changed their trousers they had nearly constant exposure to the carcinogen. New occupationallisks continue to be identified today.

Every worker may face a particular mix of biological, chemical, physical, mechanical, and psychosocial challenges at work. Some occupations carry specific risks. Those who work with heavy machinery are at risk for crush wounds from moving parts. Those exposed to loud noises are at risk for permanent hearing impairment. Medical workers are at risk for contract- ing infectious diseases from needles ticks and contact with body fluids. Some workers who have long-term exposure to industrial chemicals are at increased risk for developing certain types of cancers. Office workers are at risk for repetitive strain injuries, such as carpal tunnel syndrome, that can develop after performing the same tasks over and over. All workers may be subject to stress that can impair mental health.

The International Labor Organization (ILO) estimates that each year nearly 300 million workers miss at least 4 days of work due to an on-the-job injury and about 2 million people die as a result of job-related diseases, including more than 350,000 who die from injuries sustained at work. 28

Workplace hazards are estimated to be responsible for 37% of back pain, 16% of hearing loss, 13% of COPD, 11 % of asthma, 9% of lung cancers, 8% of injuries, and 2% of leukemias worldwide. 29 Many of these injuries and deaths could be prevented if worksite managers and government officials enforced compliance with safety regulations.

180 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

'C'."J"_V"J~~.~ is the study of the harmful effects that chemicals and other environmental hazards like radiation can have on living things. Toxicologists study the way variations in exposure frequency (how often a person is exposed), duration (the length of exposure at a given time), and dose (the amount of hazardous substance contacted) influence health. They also assess the various exposure routes (like inhalation, ingestion, and absorp- tion through the skin) and pathways (through air, water, food, soil, or other mechanisms) related to hazardous exposures. Substances identified as (which can cause genetic mutations that lead to cancer), !:eR";:;tog;en§ (which can cause birth defects), or other hazards can be regu- lated or banned. Hazardous exposures include radiation, chemical pollut- ants, and toxic substances like PCBs (polychlorinated biphenyls), dioxins, asbestos, lead, mercury, cadmium, organic solvents, and pesticides. Many of these are released into the environment through industrial activities. Some of the most common toxic substances are listed in Table 8~5. 30

Hazardous substances are estimated to cause more than 400,000 deaths each year, including 100,000 occupational deaths from asbestos and 70,000 poisoning deaths due to agricultural pesticides. 3 ! Although these hazardous substances are used and produced in industrial settings in both developed and developing countries, workers in developing countries have greater risks from them. Many highly toxic agents that have been banned from use in the United States and other industrialized nations are still used in low-income nations. Occupational regulations in low- income countries are rarely enforced, so workers generally have very little access to protective gear and safety training. And in low-income countries where jobs are scarce, workers may have to choose between repeated exposure to very high doses of dangerous chemicals and being unemployed.

I:<;,,:i!]Jt,(]lXllCGlo~~y examines the impact of toxic exposures on populations, communities, and ecosystems. When industrial accidents occur, they do not just affect people who work at the site of an incident. The pollutants, toxins, and other substances released into air or water as a result of an acci- dent can affect the local community and may spread to a much larger area. The radioactivity released during the meltdown of the nuclear reactor at Chernobyl in Ukraine (then part of the U.S.S.R.) in April 1986 spread a radioactive cloud across most of Europe. One health-related outcome of the meltdown was an increase in the incidence of thyroid cancer among children in the most contaminated regions. 32 An accident at a chemical

8.7 Toxicology 181

l"Zible flc-5 Top hazardous substances in the United States in 2007.

Substance

Arsenic

2 Lead

3 Mercury

4 Vinyl chloride

5 Polychlorinated biphenyls (PCBs)

6 Benzene

7 Cadmium

8 Polycyclic aromatic hydrocarbons (PAHs)

Uses

Used to make "pressure-treated" lumber, as a pesticide for cotton plants, and in copper and lead smelting

Used in production of batteries, ammunition, metal products (solder and pipes), and devices to shield x-rays; released from the burning of fossil fuels and during mining and manufacturing; used in some gasoline, paints, caulks, and ceramic products

Used in thermometers, dental fillings, batteries, and some antiseptic creams and ointments

Used to make polyvinyl chloride (PVC), plastic products like pipes, wire and cable coatings, and packaging materials

Used as coolants and lubricants in transformers, capacitors, and other electrical equipment

Used to make other chemicals that form plastics, resins, nylon and synthetic fibers, rubbers, lubricants, dyes, detergents, drugs, and pesticides

Extracted during production of metals like zinc, lead, and copper for use in batteries, pigments, metal coatings, and plastics

A group of over 100 different chemicals that are formed during incomplete burning of coal, oil, gas, garbage, tobacco, charbroiled meat, and other organic substances; also found in coal tar, crude oil, creosote, roofing tar, some medicines and dyes, plastics, and pesticides

Source: Information from 2007 CERCLA (Comprehensive Environmental Response, Compensation, and Liability Act) priority list of hazardous substances. Atlanta, GA: U.S. Agency for Toxic Substances and Disease Registry; 2007.

plant in Bhopal, India, in December 1984 released liquid and vapor methyl isocyanate. Several thousand people died when they were exposed to the fumes, some in their beds and others in the street after they staggered out of their homes to try to escape from the chemical. Hundreds of thousands of people sustained lung injuries?3

182 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

Another example of widespread environmental damage that can be created by human activities is air pollution, which can be produced by transportation (exhaust from cars and trucks), power plants (which burn coal and oil to produce electricity), industrial processes, forest fires, and the disposal of solid waste. The substances released into the air from these processes include carbon monoxide, sulfur oxides, hydrocarbons, nitrogen dioxide, and particulates of solid or liquid substances that are small enough to remain suspended in the air for long periods of time and are easily moved by wind. Poor air quality can cause reduced visibility and unpleasant odors, interfere with plant growth and agricultural quality, and endanger health by irritating the eyes and respiratory tract, increasing the risk of asthma, and exacerbating symptoms of chronic diseases like cardiovascular diseases, COPD, and anemia?4

Many countries from all income levels have passed occupational and environmental health and safety laws as well as laws intended to reduce new pollution. And because pollutants and hazardous materials produced in one place can end up affecting people thousands of miles away, several international regulations and guidelines are intended to protect the envi- ronment as well as human health. For example, the Kyoto Protocol, an agreement made under the Framework Convention on Climate Change, asks countries to commit to voluntarily reduce their emissions of carbon dioxide, methane, nitrous oxide, and other greenhouse gases.

AND HEA~LTH

Rural and urban households, businesses, and communities are inex- tricably linked to one another because everyone who lives or works in a community shares the same air, water, and other environmental exposures. Thus, it is advantageous to all parties when everyone works together to pro- tect their communities and to promote health. Relatively simple examples of community environmental health action include community support for enforcement of transportation policies that protect pedestrians and bicyclists and voluntary organizations that maintain recreational space to promote physical activity. Sometimes community health problems call for more dramatic and far-reaching solutions. Two examples, arsenic poison- ing from tube wells in Bangladesh and the debate over the use of DDT for malaria control, highlight different approaches to community health action.

In Bangladesh, surface water is often contaminated with feces from humans, cattle, and water buffaloes, so an initiative begun by UNICEF in

8.8 Communities and Environmental Health 183

the 1970s promoted the installation of tube wells that tap ground water. Only after millions of hand-pump tube wens had been dug did geologists determine that the wells extract water that flows through fluvial deposits that contain arsenopyrites. As a result, the concentration of arsenic in water from these wells is often tens of times higher than the recommended maxi- mum exposure (10 fJ-g/l, as advised by the World Health Organization).35 Millions of Bangladeshis are at risk for arsenicosis, chronic arsenic poison- ing from drinking contaminated water over a long period of time. 36 The most visible symptom is a change in skin color (hyperpigmentation) and the formation of hard skin patches (keratosis), but arsenicosis can also cause skin cancer and cancers of the lung, kidney, and bladder; liver damage; gangrene; and peripheral vascular disease.

An initial solution is to promote the use of a low-cost filter system that can remove arsenic from drinking water, but because even a very low-cost filter is more expensive than many Bangladeshi families can afford-and because the filters produce toxic waste, so they are at best only a temporary solution-other steps are needed. The amount of arsenic in each well var- ies widely, so workers are testing wells and then painting green handles on safe pumps and red handles on contaminated pumps?7 Another solution is to collect rainwater during the rainy season or dig deeper wells that bypass the geologic formations that contain arsenic. There is no one approach that will work for all communities, so local communities must be involved in making decisions about what will work best for their geologic, social, and economic situations.

Many more communities around the world struggle against malaria, a mosquito-borne parasitic infection. In the middle part of the 20th century, DDT (dichloro-diphenyl-trichloroethane) was sprayed in large quantities over cities and crops to control malarial mosquitoes in the United States and other countries. DDT does not easily degrade-it is a persistent organic pollutant (POP)-so it builds up in the food chain, killing birds and fish. The United States banned DDT in 1972 (in large part because of the uproar caused by Rachel Carson's book Silent Spring, which had been published in 1962), and many other countries, both developed and developing, also enacted DDT bans. The DDT ban led to a drastic increase in the incidence of malaria in many countries.

In recent years, many communities in malaria-endemic areas have begun using DDT in homes. The environmental persistence that makes DDT an environmental hazard when it is sprayed outdoors makes it appealing for in-home use as an insecticide. DDT sticks to the walls so that pesticides only need to be used once or twice a year. Spraying a tiny amount of DDT

184 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

on the walls of houses kills mosquitoes that land on the walls, but it seems to be harmless to humans and other animals. DDT is also cheaper and more effective than most other pesticides.

In 2001, a global treaty sponsored by the United Nations Environment Programme (UNEP) and many private environmental organizations banned 11 other POPs, but made a special exemption for indoor public health use of DDT. 38 Use of the chemical is now limited, but not banned. DDT is not a cure-all. It only protects people from bites while they are indoors, and some mosquitoes are resistant to the effects of DDT. Still, the World Health Organization now endorses the use of indoor residual spraying (IRS) for mosquito control in areas that have endemic or epidemic malaria transmis- sion, and DDT could contribute, if used correctly, to preventing millions of malaria deaths. 39 Although still controversial, the re-implementation of minimal use of DDT for home protection may end up being an example of how people with different views on the risks and benefits of an envi- ronmental intervention can find a middle ground that is acceptable to most parties involved.

8.9 DISCUSSION QUESTIONS

1. What are some of the safety hazards in your home? What do you do to minimize the risk from these exposures?

2. What environmental hazards might be present in your water, food, and air? What can you do to minimize your exposures? What concerns must be addressed at the population level?

3. If the water fountain at your local grocery store was your nearest source of clean water, how would you have to change your schedule and habits to accommodate this? How much time would you lose each day to waiting in line, transporting water, and otherwise meeting your water needs?

4. How would your daily activities change if you did not have access to a modern sanitation system?

5. If you had to choose whether you would have running water in (or at least near) your home or electricity in your home, which would be your priority? Why?

6. What are the occupational risks associated with your chosen profession? 7. How might companies working in your community be harming the

environment? What are local companies doing to help promote a healthier environment?

References 185

8. What are some examples of local and national organizations that focus on the environment or on environmental health? What steps do these organizations recommend individuals and families take to help foster a healthy environment? What volunteer opportunities do these organiza- tions provide?

l. Schettler T. Toward an ecological view of health: an imperative for the twenty-first century. Concord CA: The Center for Health Design; 2006.

2. Shryock RH. The early American public health movement. Am J Public Health. 1937;27:965-971.

3. Susser M, Susser E. Choosing a future for epidemiology: I. Eras and paradigms. Am J Public Health. 1996;86:668-673.

4. Bingham P, Verlander NQ, Cheal MI. John Snow, William Farr and the 1849 outbreak of cholera that affected London: a reworking of the data highlights the importance of the water supply. Public Health. 2004; 118:387-394.

5. Pearce N. Traditional epidemiology, modern epidemiology, and public health. Am J Public Health. 1996;86:678-683.

6. Doll R, Hill AB. Lung cancer and other causes of death in relation to smolting. Br Med J. 1956;2: 1071-1081.

7. Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ. 1997;315:980-988.

8. Danaei G, Vander Hoorn S, Lopez AD, Murray CJ, Ezzati M; Comparative Risk Assessment collaborating group (cancers). Causes of cancer in the world: compar- ative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005;366:1784-1793.

9. Guidelines for drinking water quality, 4th edition. Geneva: WHO; 2011. 10. Progress on sanitation and drinking water: 2010 update. Geneva: UNICEFIWHO Joint

Monitoring Programme for Water Supply and Sanitation; 2010. 11. Water for life: community water security. New York: Hesperian Foundation and

UNDP; 2005. 12. Progress on sanitation and drinking water: 2012 update. Geneva: UNICEFIWHO Joint

Monitoring Programme for Water Supply and Sanitation; 2012. 13. Estimated use of water in the United States in 2005 (circular 1344). Reston VA: U.S.

Geologcial Survey; 2009. 14. Howard G, Bartram J. Domestic water quantity, service level and health. Geneva:

WHO; 2003. 15. Little green data book 2011. Washington DC: World Bank; 2011. 16. Conant J, Fadem P. Community guide to environmental health. Berkeley CA: Hesperian

Foundation; 2008. 17. Mara D, Lane J, Scott B, Trouba D. Sanitation and health. PLoS Med. 20W;7:elO00363. 18. World energy outlook 2010. New York: International Energy Agency (lEA); 2010. 19. Legros G, Havet I, Bruce N, Bonjour S. The energy access situation in developing

countries: a review focusing on the least developed countries and sub-Saharan Africa. New York: UNDP and WHO; 2009.

186 CHAPTER 8 THE ENVIRONMENTAL CONTEXT OF HEALTH

20. Zhang J, Smith KR. Indoor air pollution: a global health concern. Br Med Bull. 2003;68:209-225.

21. Smith KR, Mehta S. The burden of disease from indoor air pollution in developing countries: comparison of estimates. Int 1 Environ Health. 2003;206:279-289.

22. Bonjour S, Priiss-Ustiin A, Rehfuess E. Indoor air pollution: national burden of disease estimates. Geneva: WHO; 2007.

23. Fullerton DG, Bruce N, Gordon SB. Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Trans R Soc Trop Med Hyg. 2008; 102: 843-851.

24. Bruce N, Rehfuess E, Mehta S, Hutton G, Smith K. Indoor air pollution. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease control priorities in developing countries, 2nd edition. Washington DC: Oxford University Press; 2006.

25. Abrams HK. A short history of occupational health. 1 Public Health Policy. 2001 ;22: 34-80.

26. Hughes RE. James Lind and the cure of scurvy: an experimental approach. Med Hist. 1975;19:342-351.

27. Waldron HA. A brief history of scrotal cancer. Br lInd Med. 1983;40:390-401. 28. Al-Tuwaijri D, Fedotov I, Feitshans I, et al. Beyond deaths and injuries: the ILO's role

in promoting safe and healthy jobs. Geneva: ILO; 2008. 29. Fingerhut M, Nelson DI, Driscoll T, et al. The contribution of occupational risks to the

global burden of disease: summary and next steps. Med Lav. 2006;97:313-321. 30. 2007 CERCLA (Comprehensive Environmental Response, Compensation, and

Liability Act) priority list of hazardous substances. Atlanta GA: U.S. Agency for Toxic Substances and Disease Registry; 2007.

31. World Day for Safety and Health at Work 2005: a background paper. Geneva: ILO; 2005.

32. Shibata Y, Yamashita S, Masyakin VB, Panasyuk GD, Nagataki S. 15 years after Chernobyl: new evidence of thyroid cancer. Lancet. 2001;358:1965-1966.

33. Mehta PS, Mehta AS, Mehta SJ, Makhijani AB. Bhopal tragedy's health effects: a review of methyl isocyanate toxicity. lAMA. 1990;265:2781-2787.

34. Brunekreef B, Holgate ST. Air pollution and health. Lancet. 2002;360: 1233-1242. 35. Smith AH, Lingas EO, Rahman M. Contamination of drinking-water by arsenic in

Bangladesh: a public health emergency. Bull World Health Organ. 2000;78: 1093-1103. 36. Chakraborti D, Rahman MM, Das B, et al. Status of groundwater arsenic contamination

in Bangladesh: a 14-year study report. Water Res. 2010;44:5789-5802. 37. Ahmed M, Jakariya M, Quaiyurn M, Mahmud SN. An implementation guide for the

Arsenic Mitigation Program. Dhaka: BRAC; 2002. 38. Sadasivaiah S, Tozan Y, Breman JG. Dichlorodiphenyltrichloroethane (DDT) for indoor

residual spraying in Africa: how can it be used for malaria control? Am 1 Trop Med Hyg. 2007;77(6 suppl):249-263.

39. World malaria report 2010. Geneva: WHO; 2010.

Most North Americans and Europeans consider cancer, heart disease, or diabetes to be their number one health concern. Few mention infectious diseases as a top priority, except when a major infectious disease outbreak is getting a lot of media attention. This happens occasionally when there are new fears about the emergence of a particularly bad influenza strain or there is an outbreak linked to a food product or restaurant chain. These worries usually fade quickly. But in many parts of the world infectious diseases remain responsible for a large proportion of deaths of children, the poor, and other vulnerable population groups 1 This fact alone is a very good reason to care deeply about developing new meth- ods for prevention and treatment of infections and increasing access to these technologies. Everyone also needs to be concerned about infectious diseases because they can spread and adapt quickly, and they have the potential to affect nearly everyone. Infectious diseases are spread through social networks, and the web of human contacts is becoming more and more complex as modern transportation allows people and products to travel to almost anywhere in the world within a day. Global health profes- sionals must know how infectious diseases are transmitted and how they can be contained.

187

188 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

100%~------------------------------------------,

80%~----------------------------------------~

60%~----------------------------------------~

40%+-----------------------------------__ ~--~

20%~-------------------------==--------

2% O%~~------~--

High Income Upper Middle Income

Lower Middle Income

Low Income

Figure 9-1 Percentage of deaths that were due to infectious and parasitic diseases in 2008, by country income level.

Source: Data from The global burden of disease: 2004 update. Geneva: WHO; 2008.

9.2 AGENTS OF INFECTION

There are many different types of pathogens that can cause infection, including bacteria, viruses, parasites, and fungi. Different infectious agents pose different risks and require different methods of prevention and treatment.

9.2.A Bacteria

Bacteria are microscopic, single-celled organisms that are found nearly everywhere on the planet, from the arctic tundra to hot springs deep in the ocean. Bacteria can be differentiated based on their shapes, such as rods (bacilli), spheres (cocci), and spirals (spirochetes, vibrios, and spirilla), by relative size (although all are very small), and by the amount of a substance called peptidoglycan in their cell walls. When stained with a special dye, the peptidoglycan on the surface of Gram-positive bacteria will bond to the stain. Gram-negative bacteria have an outer membrane over the peptido- glycan layer so the dye will not bond.

Bacteria play an important role in decomposition and chemical recycling, in the fixation of nitrogen into plants, and in the production of alcohol and foods like cheese and yogurt. Millions of helpful bacteria line the digestive

9.2 Agents of Infection 189

tracts and other surfaces of humans, crowding out hannful bacteria. However, many types of bacteria can cause disease, like some strains of E. coli, which can cause diarrhea, and Staphylococcus, which can cause skin disease.

Bacteria cause illness in a variety of ways. For example, illness from a bacterial infection may be due to bacterial endotoxins that are released when the bacteria die and disintegrate. Many gastrointestinal diseases are the result of endotoxins being released from Gram-negative bacteria. Some bacteria produce exotoxins like the one that causes botulism, which can lead to severe illness and death in people who eat food from cans that are contaminated with the toxin. Tetanus toxin from Clostridium tetani spores can cause spasms and death. The toxin enters the body when a person sustains a puncture wound (often referred to as "stepping on a rusty nail") or gives birth in unsanitary conditions, but disease can be prevented with an immunization. Several other bacterial diseases are also vaccine-preventable, including whooping cough, pneumococcal pneumonia, and bacterial men- ingitis. Most bacterial infections can be cured with antibiotics, although a growing number of (disease-causing) bacteria are becoming resistant to treatment with common antibiotics.

Viruses are extremely tiny, and because they are acellular (not cells) they are not considered to be alive. They can only replicate by invading the cells of a living host and taking control of the cells' nuclei. When a virus enters the body, spikes on the outer part of the virus, caned a capsid, attach to the surface of a human cell. The outside of the virus is shed and the genetic material from inside the virus penetrates the cell and travels to the nucleus, where the virus takes command and directs the infected cell to make many new copies of the virus. The newly formed virus copies travel to the edge of the cell and enter new capsids. When released from the cell, the new virus particles travel to other parts of the body, infecting other cells, or are shed from the body to infect other people.

The body will recover from most viral infections on its own, but some viruses lead to chronic infections, such as HIV and the hepatitis C virus. Viral infections cannot be cured by antibiotics. Treating viral infections inap- propriately by prescribing antibiotics poses a serious threat to global health by contributing to the development of antimicrobial resistance. For some types of viral infections, it is possible to take drugs that reduce the number of virus particles present in the body and that help mitigate symptoms.

190 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

For example, antiviral drugs can slow the progression of mv infection, sup- press the lesions caused by the herpes virus, and make influenza infections less severe. However, the better option is to take steps to prevent contract- ing a virus. Many viral infections can be prevented by vaccines, including polio, hepatitis B, rotavirus, human papillomavirus (HPV), measles, and chickenpox, and personal health practices such as handwashing and cov- ering one's mouth when sneezing or coughing can limit transmission of many other viruses.

9.2.C Parasites

Parasites are eukaryotic organisms that survive by living off of a host. A eukaryote consists of a complex cell or cells that have a membrane-bound nucleus. Bacteria and viruses are not eukaryotes, but fungi, plants, and ani- mals are. Some parasites only minimally affect their hosts, but others can cause serious illness or disability. There are two main types of eukaryotic parasites that affect human health: protozoa and helminths.

Protozoa are single-celled organisms that have animal-like characteris- tics and often live in water. Paramecium and Amoeba, which are often used as samples under microscopes in biology classes, are common protozoa. Protozoa are classified based on how they move and on the characteristics of their lifecycles. For example, flagellates have a "tail" that assists with motion, ciliates have rows of hair-like projections that help the organism to move, and apicomplexa (including the parasites that cause malaria, cryp- tosporidiosis, and toxoplasmosis, which can be acquired from contact with cat litter and can cross the placental barrier and cause congenital infection in the fetus) have complex life cycles involving both sexual and asexual reproduction.

Helminths are endoparasitic worms that live inside the body of the host. (Protozoa are also endoparasitic. In contrast, lice and the mites that cause scabies are ectoparasitic animals that live on the exterior surface of the body.) Helminths are classified by shape as well as by their lifecycles. Nematodes are roundworms, cestodes are tapeworms, and trematodes are flukes (flatworms). Helminths can be acquired by walking barefoot in con- taminated soil, wading in contaminated water, ingesting contaminated food or water, and even by being bit by worm-infested insects. Some worms are microscopic, but others grow to be several inches-or even several feet- long as they mature in the human body.

9.2 Agents of Infection 191

Antiparasitic medications will kill many parasites, but may not be effec- tive against all life stages of the parasites, and drug resistance is becoming a concern for many types of parasite infections.

come in many forms, including molds and yeasts. Fungi are important decomposers used to make bread, wine, and cheese, but some are pathogenic. Fungal conditions frequently occur after the bacteria that normally live in or on the body are disturbed by antibiotic use or immuno- suppression. For example, the fungus Candida albicans is normally found on human skin, especially around moist areas like the mouth, groin, and underarms, and sometimes an overgrowth of Candida, called candidiasis, occurs and presents as thrush (a white coating on the tongue), a vaginal yeast infection, or diaper rash. Other examples of fungal infections include histoplasmosis, which is spread through animal droppings, Pneumocystis carinii (PCP) pneumonia, which is common among individuals with advanced HIV infection, and dermatomycoses (fungal diseases of the skin) like ringworm and athlete's foot. Fungi thrive in moist, dark places, and are especially common in the tropics.

Prions

or "proteinaceous infectious particles," appear to cause some types of very rare degenerative nervous system diseases caned trans- missible spongiform encephalopathies (TSEs). Proteins are the build- ing blocks of cells, tissues, and organs. Normal proteins are chains of amino acids that are folded into complex shapes. Mutant prion proteins lose their shapes by unraveling and straightening out. A single mutant prion appears to be able to cause the normal proteins near it to also unravel. In "mad cow disease" (bovine spongiform encephalopathy, or BSE), the brains of cows become spongy as their brain proteins unravel. The equivalent disease in humans is caned Creutzfeldt-Jakob Disease (CJD). Infections are thought to be acquired through the ingestion of brain and nervous tissue from infected animals. Although cooking food at sufficient temperatures will kill most bacteria and parasites, heat will not kill prions because the proteins are already denatured (unraveled).

192 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

No treatment is available, so prevention is essential. Keeping livestock healthy protects humans from the risk of acquiring prions from animal- based food products. Livestock can be protected by making sure that animal feeds do not include animal proteins that could be contaminated with nervous tissue.

9.3 EXPOSURE, INFECTION, AND DISEASE

The natural history of an infectious disease describes the usual timeline from exposure to a particular agent to infection to either recovery or death (Figure 9-2).

Not all exposures to an infectious agent cause an infection. Some indi- viduals may be more vulnerable to infections when the ability of their immune systems to fight off infection is weakened by age, malnutrition, cancer treatments, immunosuppressive drugs, or existing infections with other pathogens. Other individuals may be protected from new infections by previous infections (and resulting immunity), by immunization, or by genetics. And some potentially infectious agents do not have genetic char- acteristics that allow the agent to easily infect people or easily make them sick. Infectivity is the capacity of an infectious agent to cause infection in a susceptible human (a person who does not already have immunity to the infection). Measles has a high infectivity rate because a high propor- tion of the susceptible individuals exposed to measles become infected. In contrast, leprosy has a low infectivity rate and does not easily spread to susceptible people who do not have prolonged contact with an infectious person. 2 Infectivity is sometimes measured by calculating the secondary attack rate, which is the average number of other people that one conta- gious person infects.

Infection occurs

Disease could be detected

through testing

Symptoms of disease develop

Symptoms resolve or the infected

person dies

Time---+------------~----~------~--------------~--~~ - Preclinical Phase ---i----!~-Clinical Phase

The infected person may become contagious before

the onset of symptoms

Figure 9-2 Natural history of disease.

9.3 Exposure, Infection, and Disease 193

An Mufedion occurs when an infectious agent begins to reproduce inside a person. This usually causes an immunologic response specific to the agent, and that response can often be detected through laboratory testing. Many infections have a lateni phase (also called an h1Cuh&,tjon that occurs immediately after infection. During this stage, the infectious agent multiplies in the host but the infected individual does not feel sick, even if he or she is contagious and able to spread the infection to others. Laboratory tests that detect early-stage infection can be critical for halting the spread of infection during outbreaks and for treating patients before they develop severe disease.

lLP"G'''''"'c",,, occurs when an infected person develops symptoms or illness. Not all infections cause disease. For example, most children who are infected with the hepatitis A virus remain asymptomatic (do not show disease) even though they develop lifelong immunity to the disease following their infection,3 and nearly one-third of the world's population has been infected with tuberculosis (TB), but only about 10% of those infected will develop symptoms of TB disease in their lifetimes.4 PathGgemdty is the capacity of an infectious agent to cause disease in an infected human, and it is measured by the proportion of individuals with laboratory-confirmed infection who become ill.

In those who do develop symptomatic disease, there are three possible outcomes: death, recovery with immunity, or recovery without immunity

For nearly all infections, the recovery rate is extremely high. The body's immune system will fight off most infections even if they are left untreated, and once symptoms begin, most people with severe illnesses will seek medical care and be treated for the infection if an effective therapy is available. However, in some cases an infection will be fatal with or with- out medical intervention. ViJrul.ence is the ability of an infectious agent to

9-3 Outcomes for an infected individual.

194 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

cause severe disease or death in a host, and it is measured by the proportion of severe or fatal cases among all people who have the disease. A virulent infection will have a high case fatality rate. For example, rabies is an extremely virulent infection because no one who is bitten by a rabid ani- mal survives without postbite vaccination treatment (called post-exposure prophylaxis, or PEP).

Some infections cause acute (short-term) disease, like influenza and the rhinoviruses that cause colds. Other infections cause chronic (long-term) disease, like HIV and Helicobacter pylori, a bacterial infection that can cause stomach ulcers. Chronic infections can increase susceptibility to other infections, and some chronic infections may also increase the risk of cancer. For example, hepatitis C virus increases the risk of liver cancer, chronic schistosomiasis (a helminth infection) increases the risk of bladder cancer, and HPV can cause cervical cancer.

Many infections spark an immune process that forms "memory" antibod- ies in the blood that allow the body to quickly destroy any new pathogens of the same type that invade the body in the future. These types of infections are good candidates for vaccine development. Recovery from other infec- tions may provide no protective immunity against future infections. These types of infections are not likely to be controlled through immunization, so prevention must focus on avoidance of exposure.

9.4 INFECTIOUS DISEASE TRANSMISSION

An infectious agent can be transmitted to a susceptible human through several different modes of transmission.

Direct transmission, also called person-to-person transmission, occurs when a susceptible person touches an infectious person's blood or other body fluids and then touches his or her mouth, eyes, nose, or another portal of entry. (Sometimes direct transmission also occurs when a susceptible person is close enough to a sick person to breathe in the droplets expelled when a sick person coughs, sneezes, or breathes, or to have those droplets land on their skin or eyes.) Direct transmission can also occur through sexual contact. Frequent handwashing and use of personal protective equip- ment such as gloves and condoms can help prevent direct transmission.

Airborne transmission occurs when pathogens are aerosolized or suspended in the air and people breathe in that contaminated air. Influenza, colds, and TB are examples of airborne infectious diseases. To prevent a contagious person from spreading an airborne infection to

9.4 Infectious Disease Transmission 195

susceptible people, it may be necessary to treat the patient in !solaHon by limiting his or her contact with others and by protecting other people from the air exhaled by the sick person. Facemasks can also help protect people from contracting airborne infections.

V ect!l}lrbOltTK~ infections are spread by insect vectors like mosquitoes or ticks. Malaria, Lyme disease, and dengue fever are all transmitted through insect bites. Control of vectorbome diseases can be at least partially attained through the use of insecticides or other methods of reducing the insect population. Preventing insect bites reduces the risk of susceptible humans becoming infected, and reducing insect bites also lowers the likelihood of an infected human passing the infectious agent to susceptible insects.

Animals can playa role in the infection transmission process. Rodents are frequent carriers of infections such as plague and typhus fever, which are both spread by ticks that live on those rodents. Livestock may be carriers of infectious agents such as the ones that cause African sleeping sickness (which is spread by tsetse fly bites). In some cases, animals may directly transmit infectious agents to humans. For example, rabies is spread through the saliva of infected mammals, some infectious agents that cause diarrhea can be passed from livestock and pets to people, and most strains of influ- enza that affect humans originate in bird or mammal populations.

Many diarrheal infections are acquired through the ingestion of con- taminated food or water. Fecfat"olral occurs when a person ingests products contaminated with fecal material from animals or humans. Cholera is a waterborne infection, and many infectious agents that cause diarrhea (such as Salmonella and Shigella) are spread through ingestion of fecally contaminated food. Indirect transmission can also occur as a result of contact with inanimate objects (called such as doorknobs, that serve as vehicles of transmission.

Some infections, such as HIV, have also called because the agent can be passed

from a mother to her fetus during pregnancy or delivery or to her baby through breastmilk.

To control infectious diseases in a population, several other aspects of transmission must be considered. The is the environmental home for an infectious agent. Some infections, like smallpox and mea- sles, only occur in humans. Infectious diseases that usually occur only in humans are called Some infectious agents, like the ones that cause West Nile virus, rabies, and influenza, can affect many types of animals. Infectious diseases that usually occur in animals and only occa- sionally infect humans are called zoonm.;e§. Other infectious agents have

196 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

an environmental reservoir and live in the soil (like hookworm) or water (like cholera). Controlling an infectious disease may require controlling animal populations (if that is possible), altering the environment to reduce the exposure of humans to pathogens, and educating individuals and com- munities about how to reduce their risk of infection.

The cycle of infection describes how an infectious agent cycles between different species. Measles and gonorrhea cycle only between humans, so the cycle of infection is human-human-human. Vectorborne infections like malaria have a human-insect-human cycle. Some infectious agents cycle between humans and the environment, such as cholera and hookworm. Zoonoses may have a vertebrate-vertebrate-vertebrate cycle, which on occasion can become a vertebrate-vertebrate-human cycle, as happens with rabies. Or a zoonotic disease may have an animal-insect-animal cycle that occasionally affects a human. Some infectious agents have much more complex cycles and undergo life stages in several different animal hosts and perhaps also in the environment. For example, schistosomiasis cycles from snails (which serve as an intermediate host for the Schistosoma parasite) into water into humans (which serve as the definitive host in which the parasites reach sexual maturity), t4en eggs are released from humans back into water and back into snails and the cycle begins again. Each host in the cycle of infection must be considered for inclusion in an infection control plan.

9.S DIARRHEAL AND FOODBORNE DISEASES

Infectious diseases-illnesses caused by communicable pathogens-are often classified based on the primary symptoms they cause (such as diar- rhea or respiratory disease), the mode of transmission (such as vectorborne or sexually transmitted), or by other key features of the infection or the resulting disease.

Most diarrheal infections and other forms of infectious gastroen- teritis are spread by fecal-oral transmission (Table 9-1). For example, Escherichia coli bacteria are spread via fecal contamination of food and water, including swimming pools that are not properly maintained, and by person-to~person contact. Although many strains are not harmful, some are deadly, like E. coli 0157:H7, which can cause bloody diarrhea and kidney failure (hemolytic uremic syndrome). Cholera, another bacterial infection, is also spread through contaminated water, and because the

9.5 Diarrheal and Foodbome Diseases 197

Table g~Cj Examples of diarrheal and food borne diseases.

Disease Agent Name Type of Agent

Amebiasis (amoebiasis) Entamoeba histolytica Protozoan (ameboid)

Balantidiasis (balatidiosis) Balantidium Protozoan (ciliated)

Bacillus cereus food Bacillus cereus Bacterial enterotoxin intoxication

Botulism Clostridium botulinum Bacterial toxin

Brucellosis Brucella abortus, Bacterium Brucella melitensis

Campylabacter enteritis Campy/abacter jejuni Bacterium

Cholera Vibrio cholerae Bacterium

Clostridium perfringens Clostridium perfringens Bacterial enterotoxin food intoxication

Cryptosporidiosis Cryptosparidium Protozoan (sporozoan)

Cyclosporiasis Cylclospora cayetanensis Protozoan (sporozoan)

Escherichia coli Escherichia coli Bacterium

Giardiasis Giardia Protozoan (flagellate)

Helicobacter pylori Helicobacter pylori Bacterium

Hepatitis A Hepatitis A virus Virus (picornavirus)

Listeriosis Listeria monocytogenes Bacterium

Norovirus Noroviruses Virus (calicivirus)

Paratyphoid fever Salmonella paratyphi Bacterium

Rotavirus Rotavirus Virus (reovirus)

Salmonellosis Salmonella Bacterium

Shigellosis Shigella Bacterium

Staphylococcal food Staphylococcus aureus Bacterial enterotoxin intoxication

Typhoid fever Salmonella typhi Bacterium

Source: Information from Heymann DL, editor. Control of communicable diseases manual, 19th edition. Washington DC: American Public Health Association; 2008.

198 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

bacteria can live in harsh environments, like ocean water and sewage, and can survive for long periods of time, cholera outbreaks have occurred in many parts of the world in recent years. Cholera infection causes severe watery diarrhea, and death can occur if rehydration and electro- lyte balance cannot be maintained through fluid replacement. Typhoid, paratyphoid, shigellosis, salmonellosis, and campylobacteriosis are also bacterial infectious diarrheal diseases spread through ingestion of fecally contaminated food and water or the transfer of fecal matter from the hand to the mouth.

Protozoan infections can also be spread through food and water that has been contaminated with animal feces. A 1993 outbreak of cryptosporidiosis in Wisconsin, in the United States, was caused by a failure of the water treatment system. The outbreak caused more than 100 deaths in the city of Milwaukee and made more than 400,000 people sick.s Amoebic dysentery and giardiasis cause hundreds of thousands of people around the world to become sick each year.

Viruses are even more common as a cause of diarrhea. For children, rotavirus is the most common cause of severe diarrhea. 6 Rotavirus is now vaccine-preventable, but the vaccine is not available in every part of the world. For adults, a variety of viruses, including noroviruses (often associated with cruise ship outbreaks), can cause outbreaks of gastroenteritis.

While most diarrheal infections are short-term ones, some can become chronic diseases. For example, brucellosis (also called undulant fever) can be transmitted to humans through unpasteurized dairy products, and if untreated the infection may cause chronic, cyclic fevers. Untreated Helicobacter pylori infection is associated with stomach ulcers.

Effective methods for the prevention of diarrheal diseases include safe food handling, frequent handwashing, consistent access to clean drinking water, and community-wide sanitation. These practices can also help prevent food- borne infections that do not cause diarrhea, such as listeriosis, which can be acquired from processed meats and other foods and can cause miscarriages, stillbirths, and preterm delivery if pregnant women contract the infection.

9.6 RESPIRATORY DISEASES

Upper respiratory infections like colds and lower respiratory infections like pneumonia are often caused by viruses (Table 9-2). Pneumonias caused by influenza viruses and other influenza-like illnesses (ILls) are a

9.6 Respiratory Diseases 199

Table 9-2 Examples of infectious respiratory diseases.

Disease

Aspergillosis

Blastomycosis

Coccidioidomycosis (Valley fever)

Cryptococcosis

Agent Name Type ot Agent

Aspergillus Fungus

Blastomyces dermatitidis Fungus

Coccidioides immitis Fungus

Cryptococcus neoformans Fungus

Diphtheria Corynebacterium Bacterium diphtheriae

Group A strep Streptococcus pyogenes Bacterium

Hantavirus Hantavirus Virus (bunyavirus)

Hendra virus Hendravirus Virus (paramyxovirus)

Hib Haemophilus influenzae Bacterium type b

Histoplasmosis Histoplasma capsula tum Fungus

Influenza Influenza virus Virus (orthomyxovirus)

Klebsiella pneumonia Klebsiella pneumoniae Bacterium

Legionellosis Legionel/ae Bacterium (Legionnaires' disease, Pontiac fever)

Mycoplasma pneumonia Mycoplasma pneumoniae Bacterium

Nipah virus Nipah virus Virus (paramyxovirus)

Pertussis (whooping Bordatel/a pertussis Bacterium cough)

Pneumococcus Streptococcus Bacterium pneumoniae

Psittacosis

Rhinitis (common cold)

Q fever

Tuberculosis

Chlamydia psiattaci

Rhinoviruses

Coxiella burnetii

Mycobacterium tuberculosis

Bacterium

Virus

Bacterium

Source: Information from Heymann DL, editor. Control of communicable diseases manual, 19th edition. Washington DC: American Public Health Association; 2008.

200 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

particular global concern. Other viral pneumonias, such as those caused by hantavirus, can also spark outbreaks.

Bacterial respiratory diseases are also common. Pneumococcus and Haemophilus injluenzae type B (usually shortened to "Rib") are both vaccine-preventable infections but continue to cause many child deaths around the world each year. Some respiratory infections can cause long-term damage. Strep throat, an illness caused by a type of Group A Streptococcus, is a common childhood infection that if left untreated can lead to complications such as scarlet fever or rheumatic fever, a condition that may cause permanent damage to the valves of the heart. Tuberculosis infections can cause chronic illness and require months or years of antibiotic treatment.

Fungal and parasitic causes of pneumonia are relatively uncommon compared to bacterial and viral respiratory infections, but they also occur.

Most respiratory infections are acquired through the air. Pertussis, spread via the inhalation of droplets suspended in the air, is a vaccine-preventable bacterial infection characterized by whooping sounds made when people with the disease inhale during severe coughing fits. Legionellosis, also called Legionnaires' disease (for severe disease) or Pontiac fever (for milder disease), is acquired through the inhalation of moistened water from air conditioners and hot tubs (spas). Psittacosis, also called parrot fever, is acquired when bird owners inhale the dried bird droppings of infected pets.

Prevention methods for respiratory infections include isolating infected persons, reducing exposure to smoke (which damages the respiratory tract and increases susceptibility to respiratory diseases), vaccinating members of vulnerable population groups, and encouraging frequent handwashing and the covering of the nose and mouth when coughing or sneezing.

9.7 VECTORBORNE DISEASES

A wide variety of insect vectors can transmit infectious agents to humans, including various types of mosquitos, flies, fleas, lice, and ticks (Table 9-3).

Several types of bacterial and rickettsial infections are spread by the bites of infected ticks and fleas, including Lyme disease, Rocky Mountain spotted fever, bartonellosis, and typhus. (Rickettsia are a special type of bacterium.) The "Black Death" of medieval Europe was a type of plague (a bacterial infection that still exists today), and it killed one-quarter to one-half of the population of affected cities. The usual symptoms of bubonic plague are severely swollen lymph nodes and pain, but some

9.7 Vectorborne Diseases 201

Table 9~3 Examples of vectorborne (insect-spread) diseases.

Disease Agent Name Type of Agent Vector

African sleeping Trypanosoma brucei Protozoan Tsetse flies sickness (African (flagellate) (Glossina) trypanosomiasis)

Babesiosis Babesia Protozoan Ticks (sporozoan)

Bartonellosis Bartonella Bacterium Sand flies bacilliformis (Lutzomyia)

Chagas disease Trypanosoma cruzi Protozoan Kissing bugs (American (flagellate) (Reduviidae) trypanosomiasis)

Chikungunya fever Chikungunya virus Virus Mosquitoes (togavirus)

Crimean-Congo Crimean-Congo Virus Ticks hemorrhagic fever hemorrhagic fever (bunyavirus)

virus

Dengue fever Dengue virus Virus Mosquitoes (flavivirus)

Ehrlichiosis Ehrlichia Bacterium Ticks

Japanese encephalitis Japanese Virus Mosquitoes encephalitis virus (flavivirus) (Culex)

Leishmaniasis Leishmania Protozoan Sandflies (Kala azar) (flagellate)

Loiasis (African Loa/oa Helminth Deer flies eyeworm) (filarial (Chrysops)

nematode)

Lyme disease Borrelia burgdorferi Bacterium Ticks (Ixodes)

Lymphatic filariasis Wuchereria Helminth (filarial Mosquitoes bancrofti, nematode) Brugia malayi, Brugia timori

Malaria Plasmodium Protozoan Mosquitoes (sporozoan) (Anopheles)

Plague Yersinia pestis Bacterium Fleas

Rift Valley fever Rift Valley fever virus Virus Mosquitoes (bunyavirus)

(Continues)

202 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

TaJb~e 9=3 (Continued)

Disease Agent Name Type of Agent Vector

River blindness Onchocerca volvulus Helminth Blackflies (onchocerciasis) (filarial (Simulium)

nematode)

Rocky Mountain spot- Rickettsia rickettsii Bacterium Ticks ted fever (rickettsia)

Tularemia Francisella tularensis Bacterium Ticks and others

Typhus fever Rickettsia prowazekii Bacterium Fleas, lice, (rickettsia) and mites

Viral encephalitis Eastern equine Virus Mosquitoes encephalitis, (togavirus) Western equine encephalitis, Venezuelan equine encephalitis, and others

West Nile virus West Nile virus Virus Mosquitoes (flavivirus) (Culex)

Yellow fever Yellow fever virus Virus Mosquitoes (flavivirus) (Aedes)

Source: Information from Heymann DL, editor. Control of communicable diseases manual, 19th edition. Washington DC: American Public Health Association; 2008.

cases develop a more severe pneumonic plague. Plague is transmitted to humans by a rodent flea.

Viruses spread by such as insects and arachnids (spiders, ticks, mites) are called arbGvirnses (short for arthropod-borne viruses). Dengue fever is spread by the bites of infected Aedes mosquitoes that thrive in urban areas. West Nile virus is spread by Culex mosquitoes, and typically affects animals but may also cause disease in humans. Yellow fever, Japanese encephalitis, Rift Valley fever, and Venezuelan equine encephalitis are other examples of arboviral diseases.

Vectorborne protozoan infections (including the Plasmodium parasite that causes malaria, which is transmitted by the bite of infected Anopheles mosquitoes) are of particular global health interest. Three examples of these protozoan infections highlight the diversity of these infectious diseases and the vectors that spread them.

9.7 Vectorborne Diseases 203

African sleeping sickness (trypanosomiasis) is spread by the bite of infected tsetse flies and can cause chronic fevers and headaches that lead to paralysis and death. The infection primarily affects livestock, but outbreaks among humans can occur. Without early treatment, infection with African trypanosomiasis is fatal. 7

Chagas disease, also called American sleeping sickness (and also caused by a trypanosome), is spread by "kissing bugs" that live in the cracks of low-quality houses in South America and Central America. The insects emerge at night to take bloodmeals from sleeping people. The feces of the insects contain parasites that can enter the bloodstream through the wound left after the bloodmeal. Within a few days, a sore may develop at the site of the bite, which is often near the eye. About one-third of people who are infected develop a chronic infection that can cause severe damage to the heart and digestive tract. 8

Leishmaniasis is spread by female phlebotomine sandflies, which need blood from a human or other mammal in order to develop their eggs. There are several forms of leishmaniasis. The cutaneous form produces skin lesions and can lead to permanent disfigurement. The mucosal form causes lesions on the mucous membranes of the nose, mouth, and throat The visceral form, also known as kala azar, causes chronic fevers, weight loss, anemia, and swelling of the spleen and liver, leading to death within a few years if left untreated. 9

Helminths can also be transmitted by insect bites, Two examples of vectorborne worm infections are onchocerciasis and lymphatic filaria- sis. 1O Onchocerciasis, also known as river blindness, is caused by a filarial (threadlike) parasite spread by the bite of infected black flies in parts of Africa and the Americas. Adult wonns form nodules under the skin and release new immature worms (micro filariae ) into surrounding tissues. If the nodules form near the eyes and the infection is not treated, the result can be blindness. Lymphatic filariasis (LF), also caused by a filarial infection, is transmitted by several different mosquito species. Extreme swelling of body parts (often an arm, leg, or scrotum) can occur when worms block the flow of lymph (tissue fluid) out of body tissues. LF can cause a condi- tion called elephantiasis when a limb swells and develops a coarse texture similar to that of an elephant's leg. More than 100 million people worldwide are infected with the worms that cause LF. 11

Prevention of vectorbome infections includes minimizing insect bites through the use of barriers (such as bednets and protective clothing) and chemical repellents, using insecticides to reduce insect populations, and modifying the environment to limit insect breeding grounds (such as by

204 CHAPTER CONTROL OF INFECTIOUS DISEASES

draining swamps or by removing old tires and other items that can house pools of standing water). Control of animal populations and waste manage- ment that keeps rodents and other mammals away from humans can also help to control the spread of infections that are transmitted by insects that live on mammals.

are spread by intimate contact

Bacterial STIs can be treated with antibiotics if an infected person knows that he or she has been infected, but many infections remain undiagnosed and untreated, and they can cause chronic health problems. Gonorrhea and chlamydia are both often asymptomatic (causing no symptoms) but if untreated they can cause pelvic inflammatory disease (PID), which can lead to pain and to infertility in women. Syphilis can be treated in the early stages when there is a chancre or rash, but if left untreated it may cause weakened arterial walls and nervous system impairment.

Examples of sexually transmitted infections.

Disease Agent Name Type of Agent

Chlamydia Chlamydia trachomatis Bacterium

Gonorrhea Neisseria gonorrhoeae Bacterium

Hepatitis B Hepatitis B virus Virus (hepadnavirus)

Herpes Herpes simplex virus Virus (herpesvirus)

HIV Human immunodeficiency virus Virus (retrovirus)

Phthiriasis Phthirus pubis Crab lice

Syphilis Treponema pa/lidum Bacterium

Trichomoniasis Trichomonas vaginalis Protozoan (flagellate)

Warts Human papillomavirus (HPV) Virus (papillomavirus)

Source: Information from Heymann DL, editor. Control of communicable diseases manual, 19th edition. Washington DC: American Public Health Association; 2008.

9.9 Neglected Tropical Diseases (NTDs) 205

Several STIs are caused by viruses, including HIV, herpes, hepatitis B virus (HBV), and HPV, which causes genital warts and increases the risk of cervical cancer. Vaccines for HBV (which is also spread through verti- cal transmission and contact with blood) and HPV are now available in some countries, but no successful vaccine has been developed for HIV or herpes. No cure for these infections has been discovered, so once a per- son is infected he or she will always have the infection. Some drugs, like interferon, can help suppress some viral infections, but drugs will not cure viral infections.

A few parasites, such as the Trichomonas protozoan and pubic lice, are also transmitted through sexual contact.

STIs can be prevented by abstinence from sexual activity, the use of bar- riers such as condoms that limit direct contact with body fluids (although some infections may occur even with condom use), and treatment of infected individuals so that they do not transmit the infection to sexual partners.

dJ5eases are infectious diseases that primar- ily affect the poorest regions of the world (many of which are located in the tropics) and have not been a priority for funding agencies, pharmaceutical companies, or global policymakers.12 Several of the diseases mentioned in previous sections are considered to be NTDs, including African try- panosomiasis, Chagas disease, leishmaniasis, lymphatic filariasis, and onchocerciasis (river blindness). Other NTDs that are now receiving spe- cial attention from researchers and public health partnerships include dracunculiasis (Guinea worm) and schistosomiasis, along with several very common intestinal worm infections (including ascariasis, hookworm, and trichuriasis).

Guinea worm disease is an extremely painful condition. People become infected by drinking water that contains water fieas infected with Guinea worm larva. A mature Guinea worm may grow inside the body to up to 3 feet in length, and once the worm is mature it may crawl down the inside of an infected person's leg and emerge from a painful blister near the foot. The worm can also emerge from a wrist or another body part. It can take weeks for the worm to be extracted from the body, and a person with an emerging Guinea worm is usually unable to work during this time because of pain. The worm cannot simply be pulled out of the body, because if it breaks and part of the worm is left inside the body a serious infection can

206 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

result. Instead, the worm is often tied to a stick, which is used to coil the Guinea worm as it slowly makes its way out of the human's body, at a rate of an inch or so per day. Many people with an emerging worm only feel relief from pain by putting their feet in cool water, but this causes the worm to release eggs and can contaminate drinking water supplies. There is no drug for dracunculiasis, but the prevalence of the disease is decreasing as use of water filters becomes more common. Found primarily in western and central Africa, the ultimate goal is to eradicate Guinea worm disease. 13

Schistosomiasis, sometimes called bilharziasis, is a type of flatworm that can enter the body through the skin and can then migrate to the bladder or intestines, where the worms can cause scan-ing. There are several differ- ent kinds of schistosomiasis that can be found in Africa, the Middle East, Latin America, Asia, and the Pacific. In each species, the worms infect both snails and humans, and the parasite cycles between these two species. Eggs released into water from the urine or feces of infected people can infect snails living in the water. After the worms undergo several developmental stages in snail hosts, the mature larvae are released into water and seek entry into the skin of humans who are wading in the water while fishing, washing clothes, bathing, or swimming. An effective drug called praziqu- antel cures the infection, but people who are treated for schistosomiasis are immediately susceptible to new infection when they come into contact with contaminated water. Molluscicides are sometimes used to kill the snails that live in infested waters, but snails will eventually move back into the waters, and new snail habitats are created when dams and irrigation systems are built. The prevalence of schistosomiasis increased drastically when the Aswan Dam was built on the Nile River in Egypt, when dams were built on the Senegal and Volta Rivers and other locations in West Africa, and when small dams and irrigation projects have been introduced into villages in many parts of the world. 14 The complex lifecycle of the worm makes control of schistosomiasis a challenge. IS

Ascariasis (roundworm), hookworm, and trichuriasis (whipworm) are the three most common helminth infections, and nearly 1 billion people worldwide have at least one of these parasites living in their bodies (F!guJte 16.17 All STHs are contracted via contact with soil mixed with feces that contain worm eggs. Ascariasis is the most com- mon helminth infection in the world and occurs when a person ingests eggs from Ascaris lumbricoides. The larvae hatch in the small intestine, penetrate the intestinal wall, and travel through the blood to the lungs, where they may be coughed up and swallowed and then develop in the intestines into mature, egg-producing worms. Adult worms in the intestine may grow to more than

- .... t>

II Public health problem Transmission occurs

Areas with soil-transmitted helminth infections.

, .. ' ·r

t;P'v

Source: Data from Geographical distribution and useful facts and stats. Geneva: WHO Partners for Parasite Control.

:-0 \D

~ OQ

~ ()

~ ~

~ {5 §. -. tJ r;. (I; ~

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208 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

a foot in length, and eggs passed in the stool may lead to infection in others if open defecation is practiced, Hookworm is most often acquired by walk- ing barefoot through contaminated soil because the larvae can penetrate human After passing through the bloodstream, heart, and lungs, the adult worms migrate to the gut and latch on to the intestinal wall, causing bleeding and increasing the risk of anemia, especially in children, When the eggs that cause trichuriasis are swallowed, they mature in the colon. Trichuriasis can cause digestive system symptoms, Dewonning medications (such as albendazole and mebendazole) are available for all three of these infections, but re-infection can occur quickly when eggs from the worms remain in the local environment. Mass drug administration, in which whole communities routinely receive antihelmthic drugs once or twice a year, is the primary current approach to STH prevention and control. I8

People can become hosts to other types of roundworms and also pin- worms, flatworms (which include blood, liver, lung, and intestinal flukes), tapeworms (which can be found in beef, pork, and fish), and other kinds of worms Worms contracted from contaminated soil, water, food, or feces may take up residence in the intestine, liver, lungs, blood, or other body parts, including, sometimes, the brain. Intestinal worms increase the risk of malnutrition because nutrients from food go to the worms instead of the human host.

Three bacterial NTDs are also receiving new attention: leprosy, tra- choma, and Buruli ulcer (Mycobacterium ulcerans infection). Leprosy, more formally called Hansen's disease, used to be a relatively common, disfiguring disease, and people who contracted it were often ostracized

T~b!(8; 9-5 Examples of helminth diseases.

Type of Disease Agent Name Helminth Transmission

Angiostrongyliasis Parastrongylus Nematode Ingestion of undercooked mollusks

Ascariasis Ascaris Nematode: Ingestion of soil or food lumbricoides roundworm contaminated with feces

Clonorchiasis Clonorchis Trematode: Ingestion of undercooked sinensis liver fluke freshwater fish

Diphyllobothriasis Diphyllobothrium Trematode: Ingestion of undercooked tapeworm freshwater fish

(Continues)

9.9 Neglected Tropical Diseases (NTDs) 209

T~ble 9~·5 (Continued)

Echinococcosis Echinococcus Trematode: Contact with dogs granulosus tapeworm

Enterobiasis Enterobius Nematode: Ingestion of food vermicularis pinworm contaminated with

feces

Fascioliasis Fasciola Trematode: Ingestion of undercooked liver fluke aquatic plants

Fasciolopsiasis Fasciolopsis Trematode: Ingestion of undercooked buski liver fluke aquatic plants

Guinea worm Dracunculus Nematode: Ingestion of infected disease medinensis Guinea water fleas (dracunculiasis) worm

Hookworm Ancylostoma, Nematode: Skin contact with Necator hookworm contaminated soil american us

Hymenolepiasis Hymenolepsis Trematode: Ingestion of food nana tapeworm contaminated with

feces

Paragonimiasis Paragonimus Trematode: Ingestion of undercooked lung fluke freshwater crabs

Schistosomiasis Schistosoma Trematode: Contact with bodies of (bilharziasis) blood fluke water that are home to

infected snails

Strongyloidiasis Strongyloides Nematode: Skin contact with threadworm contaminated soil

Taeniasis Taenia solium, Trematode: Ingestion of undercooked (cysticercosis) Taenia saginata tapeworm pork, beef, or other

meat

Toxocariasis Toxocara Nematode: Ingestion of soil or food round worm contaminated with feces

Trichinosis Trichinella spira/is Nematode: Ingestion of undercooked (trichinellosis) threadworm pork or other meat

Trichuriasis Trichuris trichiura Nematode: Ingestion of soil whipworm contaminated with

feces

Source: Information from Heymann DL, editor. Control of communicable diseases manual, 19th edition. Washington DC: American Public Health Association; 2008.

210 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

by their communities, but it is now able to be controlled with antibiotic treatment. 19 Trachoma blindness, caused by poor facial hygiene, remains the leading infectious cause of blindness in the world, but the number of new cases each year has been decreasing with improved access to water for washing?O Mycobacterium ulcerans causes deep ulcers, and the means of transmission remains poorly understood. 21

OTHER

A wide range of infections not listed in the previous tables also cause diseases of global concern These include various causes of encephalitis and meningitis, hemorrhagic fevers, skin lesions, and other diseases.

CON'fROlL

Individuals, communities, public health organizations, and governmental agencies all have a role to play in the control and prevention of infectious diseases. Individuals contribute to reducing the burden of infectious disease by engaging in healthy behaviors such as washing hands frequently and staying home from work or school when sick. Communities play key roles in environmental health, making sure that water supplies are kept clean and that mosquito popUlations are controlled. At the national and international levels, scientists, policymakers, and others work together to create and disseminate technologies such as new vaccines and to track and address emerging infectious disease problems.

The He5J!Hh Benlef proposes that the decision of an individual to engage in a healthier behavior is dependent on the person's percep- tions about his or her susceptibility to a disease, the severity of the dis- ease, the ability of the behavior to effectively prevent the disease, the barriers to implementing a change, and the cost-benefit ratio for taking action. 22 Health education is essential for helping individuals to make better assessments about their risk of infection and disease and about the benefits of behavior change. Health behaviorists and educators often

9.11 Infection Control and Prevention 211

Table 9-6 Examples of other infectious and parasitic diseases.

Disease Agent Name Type of Agent Key Feature

Acanthamebiasis Acanthamoeba Protozoan Can cause encephalitis

Anthrax Bacillus anthracis Bacterium Spread by spores

Buruli ulcer Mycobacterium Bacterium Causes severe skin ulcerans lesions

Candidiasis Candida albicans Fungus Causes thrush, vaginal yeast infections, and skin infections

Chickenpox / Varicella-zoster Virus Causes skin lesions Shingles virus NZv) (herpesvirus)

Cytomegalovirus Cytomegalovirus Virus Maternal infections (CMV) (herpesvirus) can harm fetuses

Dermatophytosis Several Fungus Causes ringworm (tinea, and athlete's foot (dermatomycosis)

Ebola-Marburg Ebola virus, Virus (filovirus) Cause hemorrhagic hemorrhagic Marburg virus fevers fevers

Hansen's disease Mycobacterium Bacterium Causes skin (Leprosy) /eprae lesions and nerve

damage

Hepatitis C Hepatitis C virus Virus (flavivirus) Causes liver damage

Lassa fever Lassa virus Virus Can cause (arenavirus) hemorrhagic fever

Leptospirosis Leptospira Bacterium Can cause organ failure and hemorrhage

Measles Measles virus Virus Rash and (paramyxovirus) risk of severe

complications

Meningococcal Neisseria Bacterium Causes meningitis infection meningitides

(Continues)

212 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

Tab!e 9-fj (Continued)

Disease Agent Name Type of Agent Key Feature

Mononucleosis Epstein-Barr virus Virus Causes chronic (herpesvirus) fatigue

Mumps Mumps virus Virus Causes swelling (paramyxovirus) of the salivary

glands

Naegleriasis Naeg/eria fowleri Protozoan Can cause encephalitis

Pediculosis Pediculus Lice Head and body lice

Polio Poliovirus Virus Can cause paralysis (poliomyelitis) (picornavirus)

Rabies Rabies virus Virus Causes fatal (rhabdovirus) encephalitis

Rubella (German Rubella virus Virus (togavirus) Maternal infections measles) can harm fetuses

Scabies Sarcoptes scabiei Mite Causes skin lesions

Staph infections Staphylococcus Bacterium Usually cause skin aureus lesions, but can

cause severe disease

Tetanus Clostridium tetani Bacterium Spread by spores; causes painful muscle contractions

Toxoplasmosis Toxoplasma Protozoan Maternal infections gondii (sporozoan) can harm fetuses

Trachoma Chlamydia Bacterium Can cause blindness trachoma tis

Transmissible Prion protein Cause degenerative spongiform brain damage encephalopathies (Creutzfeldt -Jakob disease, kuru)

Viral meningitis Several types of Virus Causes brain viruses inflammation

Source: Information from Heymann DL, editor. Control of communicable diseases manual, 19th edition. Washington DC: American Public Health Association; 2008.

9.11 Infection Control and Prevention 213

refer to a triad of knowledge, attitudes (or beliefs), and practices (or behaviors), which is sometimes shortened to KAr~. Once individuals understand why a behavior is healthy and believe that it is worth the effort to make a change, it is easier for them to choose to engage in healthier behaviors.

There are hundreds of relatively simple healthy behaviors that reduce the risk of an individual contracting an infectious disease, including washing hands often, following safe food handling and storage guidelines, receiving an annual influenza vaccine, wearing protective clothing when walking in wooded areas (to prevent insect bites), using a condom when engaging in sexual activity, avoiding unclean needles for injections, and wearing shoes when walking outside. There is an equally long list of the actions individuals can take to avoid passing an infection on to others, including avoiding open defecation, covering coughs and sneezes, sleeping under a bednet when sick with a vectorborne infection, and completing full courses of prescribed antibiotics.

However, the ability to practice these healthy behaviors is not merely a function of knowledge and attitudes. Access to the necessary tools and resources is also essential. Teenagers who want to practice safer sex will not be able to do so if they cannot acquire condoms. Employees with influenza who want to stay home so they do not risk making co-workers sick may not have that option if there is no sick leave policy that protects them from losing their jobs when they miss a day of work. Thus, community organiza- tions and governments that help to increase access to health resources and that create policies to facilitate healthier behaviors are also essential to the success of behavior change campaigns.

Local environmental control activities can help reduce the incidence rate for a variety of infectious diseases. For example, community prevention efforts for dengue fever focus on eliminating the standing water where the Aedes mosquitoes that transmit the four serotypes of the virus breed. 23 (No successful vaccine exists yet, as it is very difficult to develop a vaccine that is effective against all four serotypes.) Any small body of standing water, such as water that collects in old cans and discarded tires, can become a breeding ground. A single family that does not clean up its yard can put a whole neighborhood at risk, so all households in a community must be involved in dengue prevention projects.

214 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

Communities can also reduce infection transmission by increasing drinking water quality and the amount of water available to each person, ensuring access to sanitation facilities, promoting proper waste manage- ment, implementing policies that reduce air pollution, reducing mosquito populations through water drainage and insecticides, and controlling rodent and snail populations. Additionally, local and national governments can implement food safety regulations, enforce zoning laws that restrict the number of individuals who can share a dwelling unit, require pet vaccina- tion, and take other steps to minimize the infectious disease risks in the natural and built environments.

Immunization programs can be a key tool for preventing and contain- ing epidemics of vaccine-preventable diseases. Immunizations are usually developed by partnerships of scientists, clinicians, public health profession- als, and others who represent for-profit pharmaceutical companies, non- profit health organizations, and governments. These teams work together to select target diseases, to create and test new vaccines, to identify and educate the populations that would most benefit from the vaccine, and to manufacture and deliver the vaccines to those populations.

A vaccine is usually made from either a weakened (attenuated) version of the infectious agent or from an inactive virus or killed bacterium. The vaccine prompts the body's immune system to create special "memory cells" specific to the surface proteins contained in the vaccine. When a vaccinated person is later exposed to that same infectious agent in a live or active form, the body's immune system is able to quickly identify the agent and disable it before it has a chance to mUltiply. Vaccination, like a "real" infection, creates adive because the body has a lasting memory of the infection. is acquired through breastrnilk or immunoglobulin shots and lasts only a few months.)

When individuals receive a vaccination, they are not just protecting themselves from disease, they are also protecting the people around them. Reducing the proportion of a population that is susceptible to an infec- tion protects the whole population (including those who are unable to receive vaccines, perhaps because of an anergy to a vaccine component or because of another medical condition). Suppose that during an outbreak each infected person exposes about 10 other people to the infection. In a completely susceptible population, all 10 of the exposed people might

9.11 Infection Control and Prevention 215

become infected, and each of those 10 people could spread the infection to many others. But if 80% of the members of the population have been vac- cinated, only two of the initial 10 contacts are likely to result in infection, and those two newly infected people will not be able to spread the infection to many others. Herd helps contain epidemics.

Antibacterial and antiparasitic medications that cure infections are a central part of many infectious disease control programs. (Antiviral drugs that suppress viral infections, but do not cure them, can also be helpful for disease control.) Besides being healthier themselves, individuals who receive drug therapy have a reduced risk of spreading infection to others. At the population level, mass the routine distribution of antibiotics or antiparasitics to populations with high a preva- lence of treatable infections, is often used to deworm schoolchildren as part of treatment and control programs for intestinal worms and schistosomiasis. MDA is also part of onchocerciasis (river blindness) control programs. The main limitation of MDA for these helminth control programs is that the children and other medication recipients are almost immediately suscep- tible to reinfection. To be effective, MDA must be accompanied by health education and environmental hygiene programs.

A second concern of drug therapy more generally is drug resistance, which is now seen for a variety of infectious agents, including methicillin- resistant Staphylococcus aureus (MRSA), which often causes skin infec- tions, multidrug-resistant tuberculosis (MDR-TB), and drug-resistant gonorrhea. Bacteria (and some other types of infectious agents) are usually susceptible to certain types of antimicrobials, and will be killed when they are exposed to correct doses of the right classes of these medications. But a growing number of these agents have developed resistance to at least some of the types of antibiotics that were once effective against them. 24 Resistance develops because of changes in the pathogen's genes. One of the main causes of the development of seems to be the misuse of antibiotics. If someone has a mild bacterial infection, such as bronchitis or a mild ear infection, and takes antibiotics for only a few days rather than fin- ishing the entire prescription, or if that person skips a few doses, that person will have killed off the susceptible, weaker bacteria, but the hardier bacteria will survive. This is a process that biologists call selecti'o:ri. The remaining bacteria may have developed resistance to the misused drug, which means

216 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

that it will be harder for that person to fight off the infection with common antibiotics. Worse yet, that person could also spread this hardier strain to other people, for whom the common first-line antibiotics will not work at all. Another misuse of antibiotics is taking the drugs for viral infections like the common cold. The individual taking the drugs is not being helped by the antibiotic, and instead is killing off the body's helpful bacteria and allowing potentially hannful bacteria that are already in the body to proliferate. These stronger bacteria may develop drug resistance, necessitating that the infected person take yet another antibiotic.

SurveiUanc~: systems track infectious disease reports from hospitals and other information sources to look for patterns and possible outbreaks or of disease, which occur when there is an unusually high inci- dence of disease in a particular place (spatial clustering) or time (temporal clustering). Surveillance systems, which are usually run by governments, use continuous monitoring in a population so that changes can be detected quickly and appropriate control measures can be implemented.

It is not necessary to track an entire population. Usually several repre- sentative clinics or communities will be selected to participate in sentiHel

which is when information from continuous monitoring at several selected "sentinel" sites is used to alert public health officials to possible changes in community health status. If an outbreak is sus- pected, a more rigorous investigation involving additional sites can be conducted. Passive that collects reports of notifiable disease diagnoses from medical laboratories and active in which public health officials contact healthcare providers to ask about whether they are seeing particular types of disease are other means of collecting surveillance data.

The health statistics collected as part of surveillance allow communi- ties, states and provinces, and nations to know what diseases are common in their populations and to recognize when an unusual health situation has developed. Without baseline data about incidence and prevalence, it is impossible to know if unusual numbers of cases are being diagnosed. An emkm.k disease is always present in a population. An (or O!.l.tbreak) occurs when a disease is occurring more often than usual and there are more than a few sporadic occurrences of disease. A IS a worldwide epidemic, like some influenza epidemics.

9.11 Infection Control and Prevention 217

Infection conh"ol measures like behavior change, environmental and vec- tor control, vaccination, and mass drug administration can be used to limit the incidence of infection in a local area. When control measures remove all risk of new infection in a region, of the infection from that area has been achieved.

When aiming for elimination, it may be necessary during outbreaks to track down and (limit the movement of) ill individuals and all of their primary contacts and secondary contacts (people contacted by pri- mary contacts) in order to contain an outbreak. This was done in China dur- ing the 2003 SARS outbreak, and it helped to stop the spread of the virus. 25

For some infections, it is possible, at least in theory, to completely eradi- cate the infectious agent. Emdic2!:lOn is achieved when there is no risk of infection or disease anywhere in the world even in the absence of immu- nization or any other control measures. To be a candidate for eradication, the infectious agent must usually meet several criteria. There must be an intervention, such as a vaccine, that effectively interrupts the chain of trans- mission. If a vaccine is used as part of the eradication strategy, the vaccine should confer lifelong or long-term immunity to the infection. The disease must be highly pathogenic so that people who contract the disease have obvi- ous symptoms and can be easily tracked. Additionally, eradication is more likely when the infection only occurs in humans. If both humans and animals serve as hosts for the infection, it may be impossible to monitor and contain an human and animal cases.

Not all infections are appropriate candidates for eradication. Eradication campaigns require lots of staff and structural SUppOlt for intense weeks or months of mass immunization and for many years of follow-up surveillance. Because it takes a great deal of time, money, and organizational sophistication to achieve eradication, only diseases that are severe and for which there is a high likelihood of a successful campaign are targeted for eradication. A global eradication campaign cannot begin unless there is widespread political com- mitment to achieving success and a support system to ensure completion. 26

The only infectious disease eradicated thus far is smallpox. A massive worldwide immunization campaign that included re-vaccination in areas where any new case of smallpox occurred led to the successful eradica- tion of the disease in 1979. (Because several laboratories kept samples of smallpox virus, the disease is not considered to be extinct. Eradication is complete when an infectious agent is no longer found in nature. !.i,xtmcnon is complete when an agent no longer exists in nature or in the laboratory.)

218 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

i 1,000,000 ~-------------------------, ~ 900,000 +.8;;;,;9;:2::.:,0:..:5.::.5 ____________________ -1

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200,000

100,000

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Figure 9-5 Worldwide dracunculiasis (Guinea worm) incidence. Data from Monthly report on dracunculiasis cases, January-December 2010. Wkly Epidemiol Rec. 2011 ;86:91-92; and Dracunculiasis eradication: global surveillance summary, 2006. Wkly Epidemiol Rec. 2007;82:133-140; and Dracunculiasis eradication: global surveillance summary, 2005. Wkly Epidemiol Rec. 2006;81:173-182; and Guinea- worm disease: countdown to eradication. Geneva: WHO; 2012.

Polio is scheduled for eradication soon, if the global immunization plan is continued until no cases of polio exist.27 Dracunculiasis (Guinea worm disease) is also nearing eradication. Although there is no vaccine for dra- cunculiasis, education programs that emphasize filtering drinking water to remove the water fleas that carry the worm larvae and that teach infected people to stay out of water so they do not pass worm eggs to susceptible water fleas have contributed to a rapid decline in the number of cases reported each year. Prior to the start of the global eradication program there were estimated to be more than one million new cases each year, but by 2005 there were only about 10,000 cases annually, and by 2010 there were fewer than 2000 cases worldwide (Figure 9_5).28-31 Other infectious diseases are being considered for future eradication efforts.

9.12 DISCUSSION QUESTIONS

1. The most common infections in high-income countries tend to be caused by bacteria and viruses. Are you surprised by how many diseases world- wide are caused by parasites?

2. Epidemiologists use an "agent-host-environment" triad (sometimes add- ing "vector" as a fourth category) to explore the factors that contribute

References 219

to infectious disease in communities. Describe the "AHE" factors that are associated with a selected diarrheal infection, a respiratory infection, a vectorborne infection, and an ST!. How do the ARE factors differ for the four diseases you selected? What do the AREs indicate about disease control and prevention strategies?

3. The tables in the chapter classify bacteria, viruses, and other agents by categories like "causes diarrhea" and "vaccine-preventable." What are some other ways that the infectious agents listed these tables could have been arranged?

4. Of all the infectious diseases mentioned in this chapter, which one would you most like to eradicate? Why?

5. What are some specific behavioral changes you can make and actions you can take that will reduce your risk of acquiring infections?

6. What are some infectious diseases that aTe endemic in your cOillll'lunity? What are some epidemics that have occurred recently?

7. What infectious diseases meet the criteria for eradication and would be good candidates for a global eradication campaign?

1. The global burden of disease: 2004 update. Geneva: WHO; 2008. 2. Heymann DL, editor. Control of communicable diseases manual, 19th edition.

Washington DC: American Public Health Association; 2008. 3. Jacobsen KH, Koopman JS. Declining hepatitis A seroprevalence: a global review and

analysis. EpidemiolInfect. 2004;133:1005-lO22. 4. Young DB, Perkins MD, Duncan K, Barry CE III. Confronting the scientific obstacles

to global control of tuberculosis. J ClinInvest. 2008;118:1255-1265. 5. Mac Kenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of

Cryptosporidium infection transmitted through the public water supply. N Engl J Med. 1994;331:161-167.

6. Parashar UD, Burton A, Lanata C, et al. Global mortality associated with rotavirus disease among children in 2004. J Infect Dis. 2009;200(suppll):S9-S15.

7. Brun B, Blum J, Chappuis F, Burri C. Human African trypanosomiasis. Lancet. 20lO;375:148-159.

8. Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010;375:1388-1402. 9. Bern C, Maguire JH, Alvar J. Complexities of assessing the disease burden attributable

to leishmaniasis. PLoS Negl Trop Dis. 2008;2:e313. 10. Taylor MJ, Hoerauf A, Bockarie M. Lymphatic filariasis and onchocerciasis. Lancet.

2010;376: 1175-1185. 11. Bockarie MJ, Pederson EM, White GB, Michael E. Role of vector control in the global

program to eliminate lymphatic filariasis. Annu Rev Entomol. 2009;54:469-487. 12. Feasey N, Wansbrough-Jones M, Mabey DCW, Solomon AW. Neglected tropical dis-

eases. Br Med Bull. 2010:93: 179-200.

220 CHAPTER 9 CONTROL OF INFECTIOUS DISEASES

13. Caimcross S, Muller R, Zagaria N. Dracunculiasis (Guinea worm disease) and the eradication initiative. Clin Microbiol Rev. 2001;15:223-246.

14. Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J. Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk. Lancet. 2006;6:411-425.

15. King CH. Toward the elimination of schistosomiasis. N Engl J Med. 2009;360: 106-109. 16. Bethony J, Brooker S, Albonico M, et al. Soil-transmitted helminth infections: asca-

riasis, trichuriasis, and hookworm. Lancet. 2006;367:1521-1532. 17. Geographical distribution and useful facts and stats. Geneva: WHO Partners for

Parasite Control. 18. Hotez PJ, Fenwick A, Savioli L, Molyneux DH. Rescuing the bottom billion through

control of neglected tropical diseases. Lancet. 2009;373: 1570-1575. 19. Suzuki K, Akama T, Kawashima A, Yoshihara A, Yotsu RR, Ishii N. Current sta-

tus of leprosy: epidemiology, basic science and clinical perspectives. J Dermatol. 2012;39: 121-129.

20. Mariotti SP, Pascolini D, Rose-Nussbaumer J. Trachoma: global magnitude of a pre- ventable cause of blindness. Br J Ophthalmol. 2009;93:563-568.

21. Merritt RW, Walker ED, Small PL, et al. Ecology and transmission of Buruli ulcer disease: a systematic review. PLoS Negl Trop Dis. 201O;14:e911.

22. Redding CA, Rossi JS, Rossi SR, Velicer WF, Prochaska JO. Health behavior models. Int Electron J Health Educ. 2000;3(SI): 180-193.

23. Gubler DJ. The changing epidemiology of yellow fever and dengue, 1900 to 2003: full circle? Comp Immunol Microbiol Infect Dis. 2004;27:319-330.

24. Goldbert DE, Siliciano RF, Jacobs WR. Outwitting evolution: fighting drug-resistant TB, malaria, and HIV. Cell. 2012;148:1271-1283.

25. Ou J, Li Q, Zeng G, Dun Z, Qin A. Efficiency of quarantine during an epidemic of severe acute respiratory syndrome-Beijing, China, 2003. Morb Mortal Wkly Rep. 2003;52: 1037-1040.

26. Knobler S, Lederberg J, Pray LA, editors. Considerations for viral disease eradica- tion: lessons learned andfuture strategies. Workshop Summary: Forum on Emerging Infections, Board on Global Health, Institute of Medicine, National Academy of Sciences. Washington DC: National Academy Press; 2002.

27. Larson HJ, Ghinai I. Lessons from polio eradication. Nature. 2011;473:446-447. 28. Monthly report on dracunculiasis cases, January-December 2010. Wkly Epidemiol Rec.

2011;86:91-92. 29. Dracunculiasis eradication: global surveillance summary, 2006. Wkly Epidemiol Rec.

2007;82:133-140. 30. Dracunculiasis eradication: global surveillance summary, 2005. Wkly Epidemiol Rec.

2006;81:173-182. 31. Guinea-worm disease: countdown to eradication. Geneva: WHO; 2012.

The "big three" infectious diseases of greatest concern to people living in most low- and middle-income countries are HIV/AIDS, tuberculosis (TB), and malariao A comparison of these three highlights some of the challenges of global infectious disease control initiatives: each of the infections is caused by a different type of agent, each has a distinct primary mode of transmission, and each causes hundreds of thousands of deaths each year, 1 Several major global health initiatives seek to address these "big three" diseases, and others are targeting influenza and other infectionso This chapter highlights these key infectious diseases and the efforts being made to reduce the global burden from themo

10.2

Human immunodeficiency virus (HIV) is a viral infection spread when body fluids like blood, semen, vaginal fluid, or breastmilk are exchanged during sexual contact, the sharing of needles used to inject drugs, or by mother-to-child transmission (MTCT) during childbirth or breastfeedingo HIV is not transmitted through casual contact like shaking hands, sharing eating utensils, or using the same toilet, and transmission of HIV through blood transfusions is rare now that donated blood and blood products can be tested for HIY The virus destroys specialized white blood cells, such

221

222 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

Table 10-1 Comparison of HIVIAIDS, tuberculosis, and malaria.

Disease HIVIAIDS Tuberculosis (T8) Malaria

Type of infectious agent Virus Bacterium Protozoan

Infectious agent Human Mycobacterium Several immunodeficiency tuberculosis types of virus (HIV) Plasmodium

Primary mode(s) of Sexual contact Airborne Mosquito transmission and injecting by droplet spread bites

drug use

Can it be cured with No Yes Yes medication?

Number of adult and 1,BOO,000 1,300,000 BOO,OOO child deaths worldwide in 200B

Proportion of all deaths 3.1% 2.4% 1.5% worldwide in 200B

Number of deaths of 190,000 60,000 710,000 children under 5 years of age in 200B

Proportion of all under-5 2.3% 0.7% B.5% child deaths in 200B

Source: Data from The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 2011.

as CD4 + T cells, that are needed by the immune system to fight infection. (Nearly all HIV work focuses on HIV virus type 1, or HIV -1. There is also an HIV-2 virus. mV-2 accounts for only a small fraction of the HIV cases in the world, and occurs primarily in West Africa. HIV-2 progresses more slowly and causes milder symptoms than HIV-l.2)

Acquired immunodeficiency syndrome, abbreviated as AIDS, is a syndrome (a collection of symptoms) that occurs as a result of the destruc- tion of immune system cells by the mv virus. Because AIDS is a syn- drome and not an infectious agent, a person cannot "catch" AIDS from someone else. A person can become infected with HIV, and that infection can cause AIDS to develop. The constellation of diseases that occur in people with AIDS, such as Pneumocystis carinii pneumonia (PCP) and

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10.2 HIVIAIDS 223

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H)l . .] CD4 + cell count and viral load following HIV infection.

Kaposi's sarcoma, are called because they only occur when the body's immune system is weakened enough to give the infectious agents an opportunity to invade. The most common OIs in low-income countries include tuberculosis, bacterial pneumonia, chronic diarrhea, and fungal infections such as Cryptococcus?

A person newly infected with HIV may experience flu-like symptoms for a few days or weeks, but is often asymptomatic During this stage, the newly infected individual still has a normal number of CD4 cells, but there is a high viral load in the blood (many virus particles per cubic millimeter) and it is possible to transmit the virus.4

The World Health Organization (WHO) identifies four clinical stages of HIV infection and AIDS disease that follow primary infection

3 In stages 1 and 2, which can last from a few weeks to more than 20 years, the infected person is asymptomatic or has only minor symptoms like skin infections and recurrent respiratory infections. Stage 3 is marked by more severe symptoms like recurrent respiratory infections, persistent fevers, tuberculosis, mouth ulcers, and the loss of more than 10% of body weight due to chronic diarrhea. The CD4 count begins to fall and the viral load in the blood begins to rise. In stage 4, serious opportunistic

Table 10-2 WHO staging system for HIV infection and disease based on clinical classification.

Clinical Primary HIV Clinical Clinical Clinical Stage 4 Infection Stage 1 Stage 2 Stage 3 (AIDS)

HIV-associated Asymptomatic Asymptomatic Mild Advanced Severe symptoms

Weight Normal Normal Loss of less than Loss of more HIVwasting 10% of body than 10% of syndrome weight body weight

Activity level Asymptomatic Asymptomatic, Symptomatic, Bed-ridden less Bed-ridden more normal activity normal activity than 50% of the than 50% of the

day in the past day during the month past month

Examples of Acute retroviral Persistent enlarge- Minor skin Chronic Chronic diarrhea, common clinical syndrome: flu-like ment of lymph problems (like diarrhea, chronic chronic fevers, conditions symptoms about nodes in several fungal infections fevers, thrush, complex

2-4 weeks after initial parts of body and mouth ulcers); pulmonary TB, infections, and infection that resolve upper respiratory severe bacterial HIV-associated within a few weeks infections infections like cancers

pneumonia and meningitis

Source: Information from Interim WHO clinical staging of HIVIAIDS and HIVIAIDS case definitions for surveillance: African Region (WHO/HIVl2005.02). Geneva: WHO; 2005.

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10.2 HIVIAIDS 225

infections mark the onset of AIDS, and the CD4 count becomes very low (below 200 particles per mm3) and may fall to undetectable levels.

There is currently no HIV vaccine and no drug that can cure an HIV infection. However, people who have HIV infection can take antiretrovilC::ll drugs to keep the viral count low and to slow the progression of symptoms. (Also, antiretroviral drugs given as post-exposure prophylaxis immediately after a known exposure, such as a nurse or doctor being stuck by a needle used on an HIV-infected patient, may lower the risk of the exposed person becoming HIV infected.s) The best current treatment for HIV infection is called antfJcetrovirai CHAART). HAART consists of combinations (sometimes called "cocktails") of sev- eral types of drugs, including reverse transcriptase inhibitors and protease inhibitors. The median survival time after infection with HIV if a person does not take HAART is about 10 years; after onset of clinical AIDS the expected survival without HAART is less than 2 years. 2 HAART prolongs both the duration of time between infection and the onset of clinical AIDS and the time between onset of AIDS and death, extending the lives of people with HIV infection by years or even decades. 6

HAART does not work for all people with HIV because some cannot tolerate the side effects, some do not adhere to the treatment regimen and skip too many doses for the drugs to be effective, and some have a drug-resistant strain of HIV. 7,8 Even if the drugs do reduce the viral load, they do not cure the HIV infection or alleviate all symptoms. Once treatment is stopped, the levels of HIV in the blood may quickly 9 Still, millions of people with HIV infection who would benefit from access to HAART do not have access to it because they cannot afford the treatment. Only about 47% of people with HIV infection worldwide are taking antiretroviral drugS.lO Coverage rates range from only 10% in North Africa and the Middle East to 32% in East Asia, 37% in South Asia, 49% in sub-Saharan Africa, and 64% in Latin America. 10

One of the alarming characteristics of HI VIA IDS is how quickly the epi- demic emerged. The first cases of AIDS in the world were identified in the United States in homosexual men in 1981 (though cases in the United States and other parts of the world had probably occurred before the 1980s), 11 and by the early 1990s there were 10 million people worldwide living with HIV. By the mid-1990s there were 20 million people living with HIV. By the early 2000s more than 30 million people were living with HIV.12

HIV/AIDS now occurs in every part of the world, with some regions bear- ing a particularly heavy burden (Table :10··-3 and Figure especially sub-Saharan Africa. 10,13 However, even within world regions, infection

N N 0\

Tl'ibl!'l10~3 HIVIAIDS statistics in 2010.

n Number of Number of Proportion O:i

Prevalence of Number of Proportion of Proportion of Adults and Adult and Child of Global > '"r.i ""' HIV Infection Adults and Global HIV Adults Living with Children Newly Deaths Due to HIV Deaths m

Among Adults Children Living Cases in This HIV Who Are Infected with HIVIAIDS in in This ~ I<-'

Region (ages 15-49) with HIV Region Women H!V in 2010 2010 Region 0

Africa 4.7% 22,900,000 67% 59% 1,900,000 1,200,000 67% 0 r 0

The Americas 0.5% 3,000,000 2% 31% 170,000 96,000 2% i:;d ;po r

Europe 0.4% 2,300,000 4% 32% 190,000 99,000 4% >-< Z Fti

South and 0.3% 3,500,000 10% 37% 210,000 230,000 13% m n Southeast ""' >-< Asia 0 ~

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TOTAL 0.8% 34,000,000 100% 50% 2,700,000 1,800,000 100% ;po

""' ,.., -< Source: Data from Global HIVIAIDS response: progress report 2011. Geneva: WHO/UNAIDS/UNICEF; 2011.

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1{l~2 Proportions of adults ages 15-49 living with HIV infection in 2010. Source: Data from Report on the global AIDS epidemic 2010. Geneva: UNAIDS; 2011.

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228 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

rates are not uniform. For example, the prevalence of mv infection among reproductive-age adults in East and Southern Africa is about 7.1 % while the rate in West and Central Africa is about 2.8%.10

Sub-Saharan Africa is home to just over 10% of the world's population, but about two-thirds of all people with HIV infection live in the region. Nearly 5% of African adults between 15 and 49 years old have contracted HIV, and in some southern African countries more than 25% adults of reproductive age (ages 15 to 49) are infected with HIV.13 In the 1990s and early 2000s, AIDS caused life expectancy to plummet in many countries and changed the entire social structure in some parts of Africa. 14 Because nearly all infections and deaths occur in young- and middle-aged adults, older adults have been forced to take on the care of their sick adult children and their young grandchildren. If the grandparents are deceased or unable to care for children, AIDS orphans (children who have lost both parents, at least one to AIDS) often end up homeless and living on the street. The mv incidence rate has decreased in most sub-Saharan African countries when compared to peak rates, and significantly increased access to ARVs has helped to reduce the number of deaths from HIV/AIDS each year. Still, nearly 23 million sub-Saharan Africans are living with HIV, and millions who would benefits from antiretroviraldrugs do not have access to them. 10

Anyone who is exposed to blood or body fluids can contract HIV. (This is why workers are often trained to use universal precautions, such as wearing gloves, when caring for a sick person or cleaning up a spill or soiled laundry.) People in some population groups-such as paid sex work- ers, men who have sex with men (MSM), injecting drug users (IDU) , and prisoners-are at elevated risk because they may engage in high-risk behaviors that increase the likelihood of contact with blood and other body fluids. They also may have limited access to healthcare services because of discrimination. And many people are at risk because they have not been educated about HIV and HIV prevention, or do not take preventive measures because they do not think they are at risk. Health workers in all regions of the world must continue HIV I AIDS education initiatives because the incidence of new cases tends to increase when people stop worrying about their risk.

Women have greater biological and social risk of contracting HIV than men. 1S Anatomically, the walls of the vagina are thin and may tear dur- ing intercourse, facilitating the entrance of HIV into the bloodstream. Women are at least twice as likely as men to acquire HIV from an act of heterosexual intercourse. Socially, women marry at younger ages than men, may not have the power to demand condom use, and are more

10.2 HIVIAIDS 229

likely to be the victims of sexual violence. Among sub-Saharan Africans who are 15 to 24 years old, nearly three times more women than men have HIV infection. 10 In some the majority of women with HIV infection are married, and many of those women contracted HIV from their husbands. Women are often hesitant to ask their husbands and partners to use condoms, so programs that educate and encourage women and men to take measures to protect their health are important contributors to HIV prevention.

In 2010, about 3.4 million children (ages 0 to worldwide were living with HIV, about 390,000 children became infected, and 250,000 children died of HIV.lO The vast majority of these children were infected through MTCT. Babies can be infected by their mothers during pregnancy, the birth process, or breastfeeding. In the absence of any drug interventions, a baby born to an HIV-infected mother has about a 15% to 30% risk of contracting HIV during delivery.16 The likelihood of transmission is much lower if the mother takes ARV s during pregnancy, because a woman with a low viral load has a lower risk of passing the virus to her baby during delivery. 17 When HAART is used, the risk ofMTCT is about 2% or less. IS Even when a mother has not taken ARVs during pregnancy, the risk of MTCT during delivery can be reduced to less than 5% if the woman is given a single dose of nevirapine at the start of labor and her baby is given a single dose of nevirapine after delivery. 19 (Zidovudine is also commonly used to prevent MTCT.)

HIV is excreted in breastmilk, and the risk of HIV infection in babies who are breastfed for several months can be as high as 25% to 45%.16 The risk is highest in babies whose mothers are not on ARVs. Mothers with HIV infection are encouraged to use formula instead of breastmilk. However, many women living with HIV have no choice but to breastfeed their babies. Some cannot afford formula and others do not have reliable access to clean water. The risk of infant death due to diarrhea from unsafe water used to mix formula is often greater than the risk of contracting HIV through breastmilk, and women are often forced to make painful decisions about which risks they will expose their babies to.

The most important way to help control the HIV / AIDS pandemic is to emphasize prevention 10,20 One campaign uses ABC as a reminder to be Abstinent, to Be faithful if sexually active, and to consis- tently and correctly use a Condom during every sex act. The ABC approach used in Uganda is often credited with reducing the prevalence of HIV by more than half in the 1990s?1 The ABC approach works to prevent unin- fected people from contracting HIV, and also helps keep people with HIV

230 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

Table 10-4 Preventive and treatment interventions for HIVIAIDS.

Preventive Interventions (Primary Prevention)

• Safe sex, including condom use

• Unused needles for drug users

• Male circumcision

• Treatment of other sexually transmitted infections (STls)

• Safe, screened blood supplies

• Antiretrovirals (ARVs) in pregnancy to prevent mother-to-child transmission (MTCT) and after occupational exposure

• Health education on abstinence, condom use, STI treatment, ARV use to prevent MTCT, feeding substitutions for mothers with HIV

• HIV voluntary counseling and testing (VCT) so that people with HIV can take steps to prevent transmitting the virus to others

• Use of universal precautions for safety when handling blood and other body fluids

Treatment Interventions (Secondary Prevention)

• Treatment of opportunistic infections (Ols)

• Co-trimoxazole prophylaxis

• Highly active antiretroviral therapy (HMRT)

• Palliative care (pain management)

Source: Data from Global HIVIAIDS response: progress report 2011. Geneva: WHO/UNAIDS/UNICEF; 2011; and Wagstaff A, Claeson M, Hecht RM, Gottret P, Fang Q. Millennium Development Goals for health: what will it take to accelerate progress? In: Jamison DT, Breman JG, Measham AR, et aI., editors. Disease control priorities in developing countries, 2nd edition. Washington DC: Oxford University Press and IBRD I World Bank; 2006.

infection healthy. Because HIV has a lot of genetic variability, people who are infected with HIV need to protect themselves against other subtypes of the virus. (Male circumcision has also recently been shown to signifi- cantly reduce the risk of HN infection,22 but it does not negate the need to use condoms as protection against HN and other sexually transmitted infections.)

Several major global health initiatives are seeking to reduce the inci- dence of HIV infection and to prolong the healthy lives of those who do contract the virus. These include the work of PEPF AR, IA VI, The Global Fund, and others. PEPF AR (the U.S. President's Emergency Plan for AIDS Relief), initiated in 2004, provided ARVs to more than 3 million people worldwide in 2010 and is expanding its coverage.23 The International AIDS

10.3 Tuberculosis (TB) 231

Vaccine Initiative (IA VI) is developing and testing several candidate HIV vaccines?4 The Global Fund to Fight AIDS, Tuberculosis, and Malaria, funded by a variety of donor countries, foundations, private sector organi- zations, and other entities, provides financing to grant-receiving countries for programs those countries implement to address the "big three" diseases, including HIV.25

T1JBERCULOSIS eIB)

Tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis. TB can affect any part of the body, but it usually occurs in the lungs, a condi- tion caned pulmonary TB. TB used to be called consumption because people with the disease were "consumed" by it and developed a bloody cough, persistent fever, wasting, and pale skin.

A distinction is made between having TB infection (latent TB) and having TB disease (active TB). More than one-third of the world's population has been infected with the TB bacillus, but only about 5% to 10% of infected people will develop TB disease during their life- times. 26 M. tuberculosis is spread through the air, but only people with active TB disease are contagious. A person with untreated active TB may infect several other people each year, especially if they have frequent and

1 d · . 27 pro onge mteractlOns. Anyone can become infected with TB, although the rate of infection is

higher among low-income individuals and those who are undernourished, have underlying medical conditions, smoke tobacco, and/or live or work in substandard facilities that are crowded and have poor ventilation that contributes to high levels of indoor air pollution.28

Infection rates are highest in Africa and Asia, but TB occurs in every part of the world 10--3 and Table 10~.5).29 Each year about 10 million new cases ofTB disease occur, about 12 million people are living with the disease, and more than 1 million people die of TB (not including those with HIV infection who die because of co-infection with TB)?9 The incidence rate has decreased in recent decades in most world regions, especially in higher-income areas, but the rate is increasing in sub-Saharan Africa (F" 30 j'llgure

People with HIV infection are much more likely to develop active TB disease than people without HIV infection, and TB is a leading cause of death in people with AIDS. About 13% of people with TB disease world- wide also have HIV infection, but nearly 40% of sub-Saharan Africans with

D Missing data • <100

100-199

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Figure 10-3 Number of cases of TB disease per 100,000 people in 2010. Source: Data from Global TB control report 2011. Geneva: WHO; 2011.

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Table 10-5 Global TB statistics in 2010.

Number Incidence of Deaths Proportion of of New TB Number of Mortality (excluding Adults with Proportion of Disease per New Cases of Total Number from TB deaths from TB Disease New TB Cases 100,000 People TB Disease ofTB Cases per 100,000 HIVIAIDS) Who HaveHIV Who Have in 2010 in 2010 in 2010 People in 2010 Infection MDR-TB

Africa 276 2,300,000 2,800,000 30 250,000 39% 2%

South and 193 3,500,000 5,000,000 27 500,000 5% 2% Southeast Asia

North Africa 109 650,000 1,000,000 16 95,000 2% 3% and the Middle '-

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Europe 47 420,000 560,000 7 61,000 5% 12% :.:: ....... <;:, 0.,

The Americas 29 270,000 330,000 2 20,000 13% 2% 0:;. --...

TOTAL 128 8,800,000 12,000,000 15 1,100,000 13% 3% bS "-

Source: Data from Global TB control report 2011. Geneva: WHO; 2011. N V.l V.l

234 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

1400.------------------------------------------.

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Figure 10-4 Number of cases of TB disease per 100,000 people between 1990 and 2010.

Source: Data from Global TB control report 2011. Geneva: WHO; 2011.

TB have HN co-infection. 29 About one in four people with HIV / AIDS who die each year die due to TB infection. 31 Early diagnosis ofTB can be criti- cal for survival. One of the challenges of the relationship between TB and mv, especially in sub-Saharan Africa, is that people with a lung infection may delay seeking treatment because they fear that a diagnosis of TB may be accompanied by a diagnosis of AIDS.32 Delayed diagnosis creates an unnecessarily high risk of death from TB. People with an HN infection can be successfully treated for TB, but they must be strong enough to survive several months of antibiotic treatment. 33

The standard treatment regimen for TB involves taking a combination of up to five different drugs every day for six months or longer. The first two months are the most crucial, but following through with the full course of treatment is essential so that all of the bacteria, including the hardiest organ- isms, are killed. The protocol for treatment that the WHO recommends is called directly observed therapy, short-course (DOTS). The key part of DOTS is the "directly observed" component. TB patients being treated under DOTS are required to have a trained observer watch them take their pills every day. This observer might be a doctor or nurse if the person is an inpatient or reports to a clinic for his or her daily treatment, a shop- keeper or other community leader, or a family member who is supervised by another community member. If the patient misses a dose, a public health worker will track the patient down and try to ensure compliance. (Some countries have public health laws stipulating that people who are not compliant with TB treatment can be hospitalized under guard or imprisoned

10.3 Tuberculosis (TB) 235

for the duration of their treatment, but most do not enforce these regula- tions.) Still, the case n\[c, the proportion of those with TB dis- ease who are diagnosed as having the disease, is low in many places. And among those who test positive for TB (either by sputum smear microscopy or by a laboratory culture test or molecular test) and begin treatment, the t'lef8!!.dt the proportion of people who are diagnosed but do not com- plete the full course of treatment, is high in some places. 29

One of the problems that can result when people being treated for TB stop taking their drugs a few months into treatment is the emergence of multidrug-resistant TB (MDR-TB). MDR-TB that does not respond to standard antibiotic therapies is a growing problem. An estimated 3% ofTB cases worldwide are resistant to at least one TB drug, but in some countries the proportion is much higher. 29 MDR-TB can be treated using a directly observed therapy approach (through a special protocol called DOTS-Plus), but the drugs are more expensive and the course of treatment is much lon- ger, usually two years rather than six months. New concerns are arising about extensively drug-resistant TB (XDR-TB) and totally drug-resistant TB (TDR-TB)?4

A vaccine called BCG (Bacillus Calmette-Guerin) is available and used in many countries, but it provides protection for only about half of the peo- ple who receive it. 35 The standard test for TB is the PPD test (also called the Mantoux test) in which a small amount of TB bacterial protein is injected under the skin and the reaction is monitored. A person with TB will have an immune response and develop a rash at the injection site. If a person has a positive PPD test, then a chest x-ray will be taken to look for pockets of infection. The person may also take a sputum test, in which the phlegm produced by deep coughs is analyzed for the presence or absence of TB bacteria. Some workplaces and schools require employees and students to prove that they do not have TB. One of the disadvantages of BeG is that people who have received BCG usually test positive on PPD tests, so more tests are required to prove that they do not actually have TB. Several new TB vaccines are being developed and tested, but are not yet ready for widespread use.

Several interventions help reduce the individual and public health bur- den of tuberculosis 20 Control of the spread of TB also requires structures to be in place to support diagnosis and treatment, including a supply chain that provides consistent access to all essential TB medications in every country and a reporting system that allows gov- ernments to track their progress toward improved prevention, diagnosis, and treatment.

236 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

Table 10-6 Preventive and treatment interventions for tuberculosis.

Preventive Interventions (Primary Prevention)

• Directly observed treatment (DOTS) of contagious cases of TB to prevent transmission and emergence of drug-resistant strains

• Testing and treatment of contacts

• BCG immunization

Treatment Interventions (Secondary Prevention)

• Directly observed treatment (DOTS) from diagnosis until cure

• Early identification of cases with active TB disease

Source: Information from Wagstaff A, Claeson M, Hecht RM, Gottret P, Fang Q. Millennium Development Goals for health: what will it take to accelerate progress? In: Jamison DT, Breman JG, Measham AR, et aI., editors. Disease control priorities in developing countries, 2nd edition. Washington DC: Oxford University Press and IBRD I World Bank; 2006.

Clinicians, public health workers, and members of communities with a high prevalence of TB play a critical role in local and national TB control by diagnosing, treating, and supporting individuals with TB disease. At the global level, TB control efforts are being led by the Stop TB Partnership, which brings together representatives from the WHO and other international agencies, national and subnational governmental organizations, foundations, nongovernmental organizations (including patient support networks), private sector entities (including pharmaceutical and diagnostic companies), and universities and research institutions. The aims of the Stop TB Partnership include expanding access to DOTS, improving treatment ofTB-HIV co-infec- tion, addressing MDR -TB, increasing the use of advanced laboratory tests for TB, and developing new TB vaccines, diagnostic tools, and medications. 36

10.4 MALARIA

Malaria is a parasitic infection caused by protozoa of the Plasmodium species. There are five types of Plasmodium known to cause human infection: Plasmodium Jalciparum, P. vivax, P. malariae, P. ovale, and P. knowlesi. Infection with any of the five species can cause cyclic fevers, headaches, and joint pain, and can in some cases can cause organ failure and brain inflammation, especially in children. P. Jalciparum is gener- ally the most serious infection, and it causes about 90% of malaria cases worldwide. 37

10.4 Malaria 237

The parasites are passed from one human to another by female Anopheles mosquitoes that need a bloodmeal in order to produce and lay eggs. The mosquitoes usually seek out bloodmeals between sunset and sunrise. Once a bloodmeal is taken, the mosquitoes deposit their eggs in water. Any places where water collects (ponds, lakes, puddles, and even buckets and old tires that might trap rainwater) can serve as mosquito habitats. Environmental changes related to road building, mining, log- ging, agriculture, and irrigation may also create breeding sites, further increasing the mosquito population. 38 The incidence of malaria varies seasonally, and generally increases during rainy seasons when mosquito populations increase.

The malaria parasite has a very complex lifecycle (Figure 10-5). A mosquito acquires Plasmodium infection by biting an infected human. After the malaria parasites undergo several stages of development in the gut of the mosquito, they travel to the salivary gland of the mosquito and are injected into a human during a bloodmeal. Once in the human body, the parasites move to the liver and reproduce rapidly. After several days the maturing parasites enter the bloodstream and invade red blood cells, the cells that carry oxygen throughout the body. The parasites grow and divide inside the red blood cells. Every 2 to 3 days (depending on the species of Plasmodium) the red blood cells rupture, releasing parasites and toxins into the bloodstream and causing fever, chills, and anemia. The cycle can continue for 10 to 14 days or longer if untreated.

Although anyone can contract malaria, children and pregnant women are most at risk for severe complications and death. Children with malaria are at risk for developing severe anemia and cerebral malaria, which

Figure 10-5 The life cycle of Plamsodium.

238 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

is characterized by coma and convulsions. If children survive cerebral malaria, they may have permanent brain damage and learning disabilities. 39 Adults who have grown up in endemic areas usually have some degree of resistance to severe malaria.40 However, susceptibility to malaria increases during pregnancy, and complications are common because pregnant women are often anemic, having too few red blood cells to carry oxygen even before additional red blood cells are destroyed by Plasmodium. 41 As a result, babies born to mothers with malaria are at increased risk of low birthweight and other birth complications. 41

Each bout of malaria causes several days or weeks of lost productivity in terms of absence from work or school and the inability to work growing food and around the home.42 Infection is most common during the seasons when subsistence farmers grow and harvest their crops, and when malaria (or caring for people with malaria) keeps family members from being in the fields at this crucial time it can result in long-term undernutrition for all members of the household. A child may have several episodes of clini- cal malaria every year, and children carry the risk of long-term reductions in school performance due to missed class days and continued weakness from anemia. The cost of lost productivity due to malaria extends to whole countries as well. A world map of the distribution of the burden of malaria (Figure 10-6) looks very similar to a world map of the distribution of poverty.42 Malaria-endemic countries also have lower rates of economic growth than countries without malaria.43

Several hundred million acute clinical cases of malaria occur each year, resulting in more than half a million deaths, mostly of children. 37 The countries with the highest burden from malaria are in sub-Saharan Africa, where more than 90% of malaria deaths occur; parts of Asia are also significantly affected (Table 10_7).37 Most cases of malaria occur in the tropics, where mosquitoes survive year-round and environmental control of insect populations through spraying of insecticides and land and water management is limited.

Nearly half of the world's population lives in an area where malaria occurs, and it is possible that this percentage could rise. 44 Until the middle of the 20th century, malaria was endemic in the United States and Mediterranean, with cases reported as far north as Canada and Siberia. A massive insecticide spraying program led by the WHO in the 1950s and 1960s eliminated malaria from dozens of countries, but it is possible for a re-emergence to occur, especially because of increased concern over the environmental impact of spraying insecticides and the risk of mosquitoes developing insecticide resistance.45

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Figure 10-6 Number of cases malaria for every 1000 people during 2009. Source: Data from Cibulskis RE, Aregawi M, Williams R, Otten M, Dye C. Worldwide incidence of malaria in 2009: estimates, time trends, and a critique of methods. PLoS Med. 2011;8:elO01142.

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240 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

Table 10-7 Regional malaria burden in 2010.

Proportion Proportion of Global of Global Clinical Estimated Malaria

Estimated Malaria % of Malaria Number of Mortality Number of Cases in Caused by Deaths from Burden in Cases This Region P. Falciparum Malaria This Region

Africa 174,000,000 81% 98% 600,000 91%

South and 28,000,000 13% 54% 40,000 6% Southeast Asia

North Africa 10,000,000 5% 82% 15,000 2% and the Middle East

East Asia 2,000,000 1% 77% 5,000 1% and Oceania

The 1,000,000 <1% 34% 1,000 <1% Americas

Europe 200 0% 0% 0 0%

TOTAL 216,000,000 100% 91% 655,000 100%

Source: Data from World malaria report 2011. Geneva: WHO; 2011.

There are few antimalarial drugs that work today. For decades, the drug of choice for treating malaria was chloroquine, but in most parts of the world the common strains of malaria have become chloroquine-resistant and the drug is now ineffective. Strains of malaria are also becoming resistant to other drug options, such as sulfadoxone/pyrimethamine (also called SP or Fansidar) and artemisinin-based drugs. 46 The WHO strongly urges the use of artemisinin-based combination therapy (ACT), which combines at least two different antimalarial drugs (such as artemether plus lumefantrine or artesunate plus mefioquine), because combination drugs slow the emergence of drug resistance. 47 Because the parasites that cause malaria are very complex organisms, develop- ing new drugs (or developing a vaccine) is a considerable scientific challenge.

Prevention of malaria is of increasing importance as treatment is becoming more difficult (Table 10-8).20 Although travelers from nonendemic areas to

10.4 Malaria 241

T81b!e iO~8 Preventive and treatment interventions for malaria.

Preventive Interventions (Primary Prevention)

• Use of insecticide-treated bed nets (ITNs)

o Indoor residual spraying (IRS) of insecticide in epidemic-prone areas

• Intermittent presumptive treatment (lPT) of pregnant women (lPTp)

Treatment Interventions (Secondary Prevention)

• Rapid detection and early treatment of uncomplicated cases

• Treatment of complicated cases such as cerebral malaria and severe anemia

places where malaria is endemic generally take prophylactic (preventive) anti- malarial drugs, these are not fully effective in preventing disease. More impor- tantly, it is not realistic or healthy to encourage prophylactic use among people living in highly endemic areas. The cost would be high, the long-tenn effects of drug use could be potentially harmful, and widespread use of antiparasitic drugs would contribute to the development of drug-resistant Plasmodium at a time when many species are no longer susceptible to existing antimalarial drugs.

The only guaranteed way to prevent malaria is to avoid all mosquito bites. Because the mosquitoes that spread malaria bite primarily at dawn and dusk, the use of bed.nets that put a mesh barrier between people and mosquitoes and also kill mosquitoes that are near the net is highly encouraged. Field studies of ITN s show a significant reduction in child mortality when bednets are used consistently.48 It is also important for malaria patients to stay under a bednet so mosquitoes cannot bite them and become carriers of malaria. Many adults who have grown up in endemic areas continue to have parasitemia (malaria parasites in the blood) even when asymptomatic, so all people who live in at-risk areas, including both children and adults, should consistently use ITNs. ITNs must generally be re-dipped in a pyrethroid insecticide once or twice a year to maintain their effectiveness as insecticides, unless they are ~ong-Iasting insecticide-treated 11et§ that remain effective for several years. 49

Other barrier methods include wearing clothes that cover the arms and legs during the times of the day when mosquitoes are most likely to bite and having screens or curtains cover the windows and doors of houses when it is possible to do this. Insect repellents like "bug sprays" and mosquito

242 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

mats and coils are also helpful, as is reducing pooled water near the home to minimize breeding areas. Additionally, indoor residual spraying (IRS) of insecticides can help to kill mosquitoes in the home. Unfortunately, most of the households at greatest risk for malaria have little or no money available

d 1 · . 50 to spen on rna arIa preventIOn. At the global level, the Roll Back Malaria (RBM) Partnership brings

together the WHO, UNICEF, other multilateral organizations, national governments from malaria-endemic countries and donor countries, researchers, and representatives from foundations, nongovernmental organizations, academia, and the private sector in order to increase and sustain access to effective prevention and treatment technologies. 51 Other partnerships, such as the Medicines for Malaria Venture (MMV) and the Malaria Vaccine Initiative (MVI), are working to create new preventive, diagnostic, and treatment tools for reducing the burden of disease caused by malaria. 52

10.5 INFLUENZA

Global health professionals are always concerned about the potential for a worldwide influenza outbreak. Influenza viruses cause fevers and respiratory disease, and they can exacerbate existing medical conditions (especially lung and heart diseases) and lead to pneumonia. ("Stomach flu" is not caused by influenza viruses.) Although the highest fatality rates from influenza are usually among the elderly and immunocompro- mised, anyone who contracts influenza can die from it. The most seri- ous influenza pandemic in the 20th century occurred in 1918 and 1919 during World War I, and that strain killed a disproportionate number of young adults. 53

Influenza viruses affect humans and also many types of animals, includ- ing chickens, ducks, pigs, horses, and even dogs, whales, and bats. Two main types of influenza viruses cause epidemics among humans, influenza A and influenza B. Influenza A viruses are further classified based on the types of surface antigens they present. The two key surface antigens for Influenza A are hemagglutinin (H) and neuraminidase (N). Influenza A strains are classified using abbreviations like H3N2 and HINI that are derived from the hemagglutinin and neuraminidase types. Surface antigens are proteins that are "read" by the body's immune cells. When an immune cell "reads" another cell that is part of the body, it recognizes that it is see- ing itself. Immune cells can also recognize some of the infectious agents

10.5 Influenza 243

that the immune system has fought off before and can quickly respond to stop these infections from reoccurring. This kind of active immunity can result from either previous infection or from immunization.

All infectious agents, whether newly emerging or long established in a population, are constantly adapting and changing in ways that can make them more or less transmissible, infective, pathogenic, and virulent. Influenza viruses fool the bodies of their hosts by changing their surface antigens so that the hosts' immune systems cannot recognize them. There are two processes for changing surface antigens. drift occurs when small genetic mutations bring about small changes in the antigens. Antigenic drift is why infection with one version of H3N2 influenza may not confer immunity to another form of H3N2. Antigenic drift makes it necessary to develop a new influenza vaccine every year. shift occurs when two very different influenza viruses attack the same cell and the genetic material from both recombines to form a new type of influenza. Antigenic shift led to the emergence in 1997 in Southeast Asia of the H5Nl strain of avian influenza that spread rapidly through the bird population, affecting both domestic birds (like ducks and chickens) and wild migrat- ing fowl. On occasion, a human becomes infected with one of these new strains of "bird fiu" and becomes seriously ill. A pandemic may result if that strain develops the ability to be easily transmitted from human to human. A pandemic occurred in 2009 when a type of HINI "swine flu" began circulating widely in the human population. 54

Influenza is a prime example of how global travel can contribute to the spread of newly mutated infectious agents. An infected person can fly to any part of the world in a day or two and spark a new epicenter of infection. On the other hand, global travel and communication may also help contain a pandemic by enabling medical equipment and knowledge to be quickly shared and public health officials to be immediately alerted to possible influenza outbreaks. During the 2009 HINI pandemic, revised International Health Regulations guided the coordinated global response to the outbreak. Countries reported cases of HlNI to the WHO, and the WHO used its Pandemic Alert System to keep member nations and the public informed about the spread ofthe epidemic. 55 Coordinated vaccine capacity-building efforts initiated before the pandemic allowed pharmaceutical companies around the globe to expedite the development, testing, and manufactur- ing of HINI vaccines. 56 Local, national, and global preparedness plans implemented years before the emergence of HINI guided the response to the pandemic, and refined plans are available for implementation when the next major influenza pandemic emerges.

244 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

10.6 OTHER GLOBAL INFECTIOUS DISEASE INITIATIVES

A variety of additional global initiatives are seeking to control or eradi- cate other infectious diseases. Some of these programs are disease specific. For example, the Global Polio Eradication Initiative, a public-private part- nership led by the WHO, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), and Rotary International, among others, has decreased the incidence of polio infection worldwide by 99% and hopes to achieve eradication within a few years.57 Some initiatives are focused on technol- ogy. For example, the GAVI Alliance assists lower-income countries with gaining access to new vaccines as quickly as possible after they are devel- oped, tested, and shown to be safe. 58 The specific vaccines GA VI helps countries to acquire are tailored to each partner country's needs.

A growing number of projects are targeting neglected tropical diseases (NTDs). The Carter Center, founded in 1982, is seeking to eradicate Guinea worm and to widely control river blindness, lymphatic filariasis, schistoso- miasis, and trachoma in areas where these infections have been endemic. 59 In 2012, the Bill & Melinda Gates Foundation, several major pharmaceu- tical companies, and other partners announced a plan to seek to control 10 key NTDs (including leprosy, African sleeping sickness, Chagas disease, visceral leishmaniasis, and soil-transmitted helminths) by 2020. 60

All of these disease control programs, and the ones for HIV / AIDS, tuberculosis, malaria, and influenza, require the financial, technical, and operational support of dozens of different players, including international and national governmental agencies, a variety of nongovernmental organi- zations, businesses, charitable foundations, scientists and other researchers, health professionals, and local volunteers. The success of these partnerships depends on the commitment all of the involved parties make to achieving public health goals.

10.7 DISCUSSION QUESTIONS

1. Most people with HIV infection would benefit from ARV therapy, but many do not have access to these drugs. What are some of the barriers to accessing these medications? What are some ways that these barriers can be overcome?

2. What are some of the factors contributing to the increase in HIV inci- dence and prevalence in some world regions and the decrease in other regions? How could additional infections be prevented?

References 245

3. What are some of the special populations at risk for HIV infection? What are some public health interventions that would reduce the infec- tion rate in these populations?

4. What are some of the reasons why every country in the world needs to be concerned about TB?

5. Why does malaria continue to kill millions of children each year even though there are many tools available to prevent malaria infection? What additional steps can be taken to prevent malaria deaths?

6. Compare and contrast the global impact of HI VIA IDS, malaria, and TB. 7. How did you react to the emergence of the HINI strain of influenza?

Did you alter your routines in any way? How will you react to the next strain of influenza that emerges?

8. How should individuals, households, communities, schools, and nations prepare for a possible influenza outbreak?

9. Visit the website for an organization or partnership seeking to control, eliminate, or eradicate a particular infectious disease. What progress is being made toward the organization's goal?

REFERENCES

l. The global burden of disease: 2004 update (May 2011 update). Geneva: WHO; 201l. 2. Jaffar S, Grant AD, Whitworth J, Smith PG, Whittle H. The natural history of HIV-l

and HIV-2 infections in adults in Africa: a literature review, Bull World Health Organ. 2004;82:462-469.

3. Interim WHO clinical staging of HIv/AIDS and HIv/AIDS case definitions for surveil- lance: African Region (WHO/HIV/2005.02). Geneva: WHO; 2005.

4. Daar ES, Little S, Pitt J, et al. Diagnosis of primary HIV-l infection: Los Angeles County Primary HIV Infection Recruitment Network. Ann Intern Med. 2001; 134:25-29.

5. Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS; U.S, Public Health Service. Updated U.S. Public Health Service guidelines for the management of occu- pational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1-17.

6. Hammer SM, Eron JJ Jr, Reiss P, et al. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society-USA panel. lAMA. 2008;300:555-570.

7. Ammassari A, Murri R, Pezzotti MP, et al. Self-reported symptoms and medication side effects influence adherence to highly active antiretroviral therapy in persons with HIV infection. J Acquir Immune Defic Syndr. 2001;28:445-449.

8. Unge C, Sodergard E, Marrone G, et aL Long-term adherence to antiretroviral treatment and program drop-out in a high-risk urban setting in sub-Saharan Africa: a prospective cohort study. PLoS One. 201O:5:e13613,

9. Garcia F, Plana M, Vidal C, et al. Dynamics of viral load rebound and immunological changes after stopping effective antiretroviral therapy. AIDS. 1999; 13 :F79-F86.

246 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

10. Global HIVIAIDS response: progress report 20ll. Geneva: WHOIUNAIDSIUNICEF; 2011.

11. Pneumocystis pneumonia-Los Angeles, 1981. MMWR Morb Mortal Wkly Rep. 1981 ;30:250-252.

12. AIDS epidemic update 2007. Geneva: UNAIDS; 2007. 13. Report on the global AIDS epidemic 2010. Geneva: UNAIDS; 2011. 14. Report on the global AIDS epidemic 2008. Geneva: UNAIDS; 2008. 15. Higgins JA, Hoffman S, Dworkin SL. Rethinking gender, heterosexual men, and

women's vulnerability to HIY/AIDS. Am 1 Public Health. 2010;100:435-445. 16. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIY

transmission in resource-poor countries: translating research into policy and practice. lAMA. 2000;283:1175-1182.

17. Yolrnink J, Siegfried NL, van der Merwe L, Brocklehurst P. Antiretrovirals for reducing the risk of mother-to-child transmission of HIY infection. Cochrane Database Syst Rev. 2007;(l):CD00351O.

18. Marseille E, Kahn JG, Mmiro F, et al. Cost effectiveness of a single-dose nevirapine regimen for mothers and babies to decrease vertical HIY-1 transmission in sub-Saharan Africa. Lancet. 1999;354:803-809.

19. Mcintyre J. Strategies to prevent mother-to-child transmission ofHIY. Curr Opin Infect Dis. 2006;19:33-38.

20. Jamison DT, Breman JG, Measham AR, et al., editors. Disease control priorities in developing countries, 2nd edition. Washington DC: Oxford University Press and IBRD/ World Bank; 2006.

21. Murphy EM, Greene ME, Mihailovic A, Olupot-Olupot P. Was the "ABC" approach (abstinence, being faithful, using condoms) responsible for Uganda's decline in HIY? PLoS Med. 2006;3:e379.

22. Sawires SR, Dworkin SL, Fiamma A, Peacock D, Szekeres G, Coates TJ. Male circumcision and HIY/AIDS: challenges and opportunities. Lancet. 2007;369:708-713.

23. The U.S. President's Emergency Plan for AIDS Relief 7th annual report to Congress. Washington DC: PEPFAR; 2011.

24. 2010 annual progress report. New York: IAYI; 2011. 25. Making a difference: global fund results report 20ll. New York: The Global Fund;

2011. 26. Dye C, Williams BG. The population dynamics and control of tuberculosis. Science.

2010;328:856-861. 27. Sepkowitz KA. How contagious is tuberculosis. Clin Infect Dis. 1996;23:954--962. 28. Lonnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of

tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med. 2009;68:2240-2246.

29. Global TB control report 20ll. Geneva: WHO; 2011. 30. Dye C, Lonnroth K, Jaramillo E, Williams BG, Raviglione M. Trends in tuberculosis

incidence and their determinants in 134 countries. Bull World Health Organ. 2009;87:683-39l.

31. Getahun H, Gunneberg C, Granich R, Nunn P. HIY infection-associated tuberculosis: the epidemiology and the response. Clin Infect Dis. 201O;50(suppI3):S201-S207.

32. Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health. 2008:8: 15.

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33. Harries AD, Zachariah R, Corbett EL, et a1. The HIV-associated tuberculosis epidemic: when will we act? Lancet. 20lO;375:1906-1919.

34. Velayati AA, Masjedi MR, Farnia P, et a1. Emergence of new forms of totally drug-resistant tuberculosis bacilli: super extensively drug-resistant tuberculosis or totally drug-resistant strains in Iran. Chest. 2009;136:420-425.

35. Colditz GA, Brewer TF, Berkey CS, et a1. Efficacy of BCG vaccine in the prevention of tuberculosis: meta-analysis of the published literature. lAMA. 1994;27 :698-702.

36. Stop TB Partnership annual report 2010. Geneva: WHO; 2010. 37. World malaria report 2011. Geneva: WHO; 2011. 38. Yasuoka J, Levins R. Impact of deforestation and agricultural develop-

ment on anopheline ecology and malaria epidemiology. Am 1 Trop Med Hyg. 2007;76:450-460.

39. Idro R, Jenkins NE, Newton CR. Pathogenesis, clinical features, and neurological outcomes of cerebral malaria. Lancet Neuro. 2005;4:827-840.

40. Doolan DL, Dobafio C, Baird JK. Acquired immunity to malaria. Clin Microbiol Rev. 2009;22: 13-36.

41. Desai M, ter Kuile FO, Nosten F, et a1. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis. 2007;7:93-104.

42. Cibulskis RE, Aregawi M, Williams R, Otten M, Dye C. Worldwide incidence of malaria in 2009: estimates, time trends, and a critique of methods. PLoS Med. 20l1;8:e1001142.

43. Sachs J, Malaney P. The economic and social burden of malaria. Nature. 2002;415 :680-685.

44. Hay sr, Guerra CA, Tatam AJ, Noor AM, Snow RW. The global distribution and popUlation at risk of malaria: past, present and future. Lancet Infect Dis. 2004;4:327-336.

45. Mendis K, Rietveld A, Warsame M, Bosman A, Greenwood B, Wernsdorfer WHo From malaria control to eradication: the WHO perspective. Trop Med Int Health. 2009;14:802-809.

46. Plowe CY. The evolution of drug-resistant malaria. Trans R Soc Trap Med Hyg. 2009;103(SuppllO):SI1-S14.

47. Guidelinesfor the treatment of malaria, 2nd edition. Geneva: WHO; 2010. 48. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane

Database Syst Rev. 2004;(2):CD000363. 49. WHO Global Malaria Program. Insecticide-treated mosquito nets: a WHO position

statement. Geneva: WHO; 2007. 50. Barat LM, Palmer N, Basu S, Worrall E, Hanson K, Mills A. Do malaria control

interventions reach the poor? A view through the equity lens. Am 1 Trap Med Hyg. 2004;7l(2 suppl):174-178.

51. Roll Back Malaria global strategic plan 2005-2015. Geneva: WHO; 2005. 52. Sachs JD. A new global effort to control malaria. Science. 2002;298:122-124. 53. Brundage JF, Shanks G. Deaths from bacterial pneumonia during the 1918-19 influenza

pandemic. Emerg Infect Dis. 2008;14: 1193-1199. 54. Novel Swine-Origin Influenza A (HIN1) Virus Investigation Team; Dawood FS,

Jain S, et 301. Emergence of a novel swine-origin influenza A (HINl) virus in humans. N Engl 1 Med. 2009;360:2605-2615.

55. Gostin LO. Influenza A(HINl) and pandemic preparedness under the rule of international law. lAMA. 2009;301:2376-2378.

248 CHAPTER 10 GLOBAL INFECTIOUS DISEASE INITIATIVES

56. Girard MP, Tam JS, Assossou OM, Kieny MP. The 2009 A (HlNl) influenza virus pandemic: a review. Vaccine. 2010;28:4895-4902.

57. Polio Global Eradication Initiative. Annual report 2010. Geneva: WHO; 201 I. 58. GAV1 Alliance progress report 2010. Washington DC: GAVI Alliance; 2010. 59. The Carter Center. Annual report 2009-10. Atlanta GA: The Carter Center; 2010. 60. Molyneux DH. The 'Neglected Tropical Diseases': now a brand identity; responsibilities,

context and promise. Parasit Vectors. 2012;5:23.

Every person needs to eat on a regular basis to provide his or her body with energy and the materials needed to build and repair cells and tissues, fight infections, and stay warm. The body requires mac1'mmtdenis such as carbohydrates, protein, and fats and oils in relatively large quantities because they provide energy. Small amounts of like vita- mins and minerals are also needed. This chapter begins with an overview of the nutrients that all people need, and then discusses the problems asso- ciated with taking in too few or too many calories and nutrients. Diseases associated with undernutrition and diseases associated with obesity are both major global health problems.

1.1.2 MACRONUTRIEf'n'S

,<I1l,,,I .. ,,,,,h·,,,,·j·,,,, are found in cereal grains like rice, maize, and wheat (the three most common staple foods in the world), in starchy roots like potatoes and yams, and in fruits and vegetables. Carbohydrates (also called

are chains of sugars. When the body requires a quick source of energy, the body's cells break down carbohydrates through a process called cellular respiration. Simple carbohydrates are made up of very short chains of sugars and are easily absorbed into the bloodstream. The lactose found in milk and the glucose and fructose found in fruits and honey :3Ie all simple

249

250 CHAPTER 11 GLOBAL NUTRITION

sugars. Table sugar, or sucrose, is a disaccharide ("two sugar") composed of glucose and fructose. Complex carbohydrates (often classified as starches), such as those found in whole grain products like whole wheat bread and oatmeal, are made up of longer chains of sugars (polysaccharides) and take longer to digest, which is why eating complex carbohydrates keeps a person from feeling hungry longer than eating simple sugars. Fiber, found in unpro- cessed plant-based foods, is another type of carbohydrate and is essential for healthy digestion because it provides bulk that moves food material through the intestines. Nutritionists recommend that for most people 45% to 65% of calories taken in over a day should come from carbohydrates.!

Proteins are chains of amino acids. Amino acids from food are broken down and reassembled in the cells to form new proteins. The keratin that makes up hair and nails, the hemoglobin in blood that transports oxygen, the antibodies that help the body's immune system recognize and fight infection, the actin and myosin that contract and relax muscles, and the collagen in ligaments, tendons, and skin are all types of proteins. There are more than 20 different kinds of amino acids. Humans are unable to produce eight of these amino acids, and must acquire those essential amino acids from food. Proteins from animal-based foods are usually complete proteins that contain all of the essential amino acids. Plant proteins are usually incomplete proteins, but eating a diverse diet with a variety of complementary proteins like maize (com) with beans or nuts and whole wheat bread can provide all of the amino acids in one meal. Nutritionists generally recommend that for most people 10% to 35% of daily calories should come from high-quality proteins.! In some regions of the world the typical diet includes too little protein, and this can cause health problems (Figure 11_1).2

Fats and oils are both types of lipids, or fatty acids, which are carbon- hydrogen chains with other chemical groups at the ends of the chains. Fats are lipids of animal origin like butter and lard that are solid at room temperature. Oils are lipids of plant origin like com oil and olive oil that are liquids at room temperature. Lipids contain more energy per gram than any other biological molecule and provide long-term energy storage, insulation, protective padding around internal organs, and assistance with nutrient absorption. They are needed for the process- ing of some vitamins (A, D, E, and K), and are used by the body to make other compounds, such as steroid hormones (chemical messengers). Nutritionists recommend that about 20% to 35% of calories consumed in a day should come from healthy fats and oils.! In some parts of

...

o No data III <10% .2:10%

Figure 11-1 Percent of calories from protein between 2005 and 2007. Source: Data from Food and Agriculture Organization (FAO) of the United Nations. FAO statistical yearbook 2012. Rome: FAO; 2012. Table 16: Dietary energy supplies and changes in dietary composition.

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252 CHAPTER 11 GLOBAL NUTRITION

the world the average person takes in too few calories from fats and oils, while in other places the average daily intake far exceeds the recom- mended amount (Figure 11_2).2

Not all fatty acids are equally healthy. The relative healthiness of lipids is often related to the amount of hydrogen they contain. Unsaturated fatty acids contain at least one double bond in the car- bon chain. Both monounsaturated fats like those found in olive oil, avocados, and nuts and the polyunsaturated fats in cold water fish like salmon (which contain omega-3 fatty acids) seem to be protective against heart disease. 3 Saturated fatty acids are found in meat, butter, and other animal products and can contribute to blocked arteries. The term saturated fatty acid refers to the fact that the molecule is "satu- rated" with hydrogen, meaning that no more hydrogen can be added to it because only single bonds exist between its carbon atoms. Trans fats, liquid oils that have been transformed into solid fats by adding hydrogen to them through the use of pressure, are found in margarine and processed foods and have been shown to raise "bad" (or "lousy") LDL (low-density lipoprotein) cholesterol while depleting "good" (or "healthy") HDL (high-density lipoprotein) cholesterol. When the LDLI HDL ratio is high, the excess fat in the blood is deposited on the walls of blood vessels as plaque. 4 When there is a lot of plaque lining the blood vessels, the resulting atherosclerosis increases the risk of having a heart attack or stroke.

Water, though not a nutrient, is also an essential part of the diet. Every cell in the body needs a way to take in oxygen and nutrients along with a way to get rid of carbon dioxide and waste. Blood, which is about 92% water, is the medium for transporting gases, nutrients, and wastes throughout the body. Without adequate blood volume-without adequate water in the body-blood pressure drops and it is difficult for the body's cells to function. A person who loses a lot of blood due to an injury or a lot of water due to excessive vomiting or diarrhea can go into hypovo- lemic shock, shock caused by too little blood volume. Water also helps the body regulate its temperature by sweating and helps the body get rid of waste through urination and defecation. An adult loses about 2 to 3 quarts of water a day by urinating, sweating, and exhaling humidified air. More may be lost in hot climates, during intense physical activity, or when a person has diarrhea. This lost water must be replaced to avoid dehydration. Severe dehydration can cause an imbalance of the acids and bases in the blood, loss of muscle tone, organ failure (especially of the kidneys), and death.

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D No data <20%

20% to 35%

II >35%

11~2 Percent of calories from fat between 2005 and 2007.

Source: Data from Food and Agriculture Organization (FAO) of the United Nations. FAO statistical yearbook 2012. Rome: FAO; 2012. Table 16: Dietary energy supplies and changes in dietary composition.

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254 CHAPTER 11 GLOBAL NUTRITION

11.3 MICRONUTRIENTS

Vitamins act as regulators and help the body use energy. There are more than a dozen vitamins necessary for health, and most of them must be included in the diet. For example, folate (or folic acid) must be ingested daily because the chemical is not able to be stored by the body. Folic acid is necessary for growth and red blood cell production. Women of child- bearing age need to make sure that they have an adequate intake of folic acid, because deficiency during the first weeks of pregnancy is associated with neural tube defects in developing fetuses. (The most common neural tube defects are anencephaly, a fatal condition in which the brain fails to develop, and spina bifida, in which the spinal cord does not develop properly.) These defects occur very early in the pregnancy, usually before a woman knows she is pregnant, so it is recommended that all women who might become pregnant take a multivitamin. Vitamin C is another vitamin that must be part of the diet. It is an antioxidant that reduces free radicals (ions in the cells that may damage cell membranes), and it helps the body absorb iron and create collagen, which is essential for maintain- ing healthy gums, skin, and other tissues. A few vitamins can be produced by the body. For example, vitamin D, which is essential for bone strength, can be made by the body when the skin is exposed to sunlight (though some individuals require supplemental vitamin D in order to reach the recommended blood levels for the vitamin). Table 11-1 summarizes the main functions of key vitamins and the problems that may occur when a person is vitamin deficient, such as pellagra, beriberi, scurvy, rickets, and osteomalacia.

Minerals help the body to build strong bones, transmit nerve signals, and maintain a normal heart rate, among other critical functions. Minerals like calcium, phosphorus, magnesium, sulfur, chloride, copper, selenium, and manganese must be taken in through the diet. Some minerals, like zinc, promote growth and wound healing. Others, like sodium and potas- sium, are electrolytes that contribute to maintaining blood chemistry, blood pressure, and, in the case of potassium, a regular heartbeat. Fluoride is essential for the development of strong teeth and bones, so some com- munities add fluoride to drinking water to ensure that children have an adequate intake of the mineral. As with any nutrient, either a deficiency or an excess of minerals can be harmful. Some people develop problems by overdosing on vitamin and mineral supplements. Others add too much salt to their foods, and excess sodium can increase the risk of high blood pressure in some adults. Even fluoride, which has dramatically improved

11.3 Micronutrients 255

!£lb!e 1'1-1 Vitamin nutrients.

Vitamin Key Function(s) Problems of Deficiency

Biotin Metabolism Skin rash; mental changes (vitamin B7)

Folate Cell production Anemia; neural tube defects (vitamin B9) in babies born to mothers

who are deficient

Niacin Metabolism; skin health; Pellagra: dark, peeling rash (vitamin B3) digestive and nervous on skin exposed to sun;

system function diarrhea; mental changes

Pantothenic acid Metabolism; red blood Paresthesia (numbness and (vitamin B5) cell production tingling of limbs)

Pyridoxine Cell production Anemia; seizures (vitamin B6)

Riboflavin Metabolism; skin and eye Cracked lips; mouth and (vitamin B2) health throat sores; scaly skin

Thiamine Metabolism; nerve Beriberi: weakness; heart (vitamin B1) function arrhythmias; heart failure

Vitamin A Eye, skin, and bone Increased susceptibility to (retinol + carotene) health; immune system infection and death; night

function blindness; blindness

Vitamin B12 Cell production Anemia; mental changes

Vitamin C Collagen formation; Scurvy: bone pain; bleeding (ascorbic acid) metabolism; immune gums and loose tooth

system function; antioxidant

Vitamin D Bone growth and health Rickets (in children): bowed legs or knock knees, spinal deformities, swollen bones in wrists, muscle weakness; osteomalacia (in adults): bone pain, fractures, muscle weakness

Vitamin E Antioxidant Anemia

Vitamin K Blood clotting Bleeding disorders

256 CHAPTER 11 GLOBAL NUTRITION

dental health, can cause weak bones and teeth if excess fluoride (fluorosis) replaces some of the calcium in teeth, stains teeth brown, and causes teeth to become pitted or break. Table 11-2 summarizes the main functions of key minerals and the problems associated with mineral deficiencies.

Table 11-2 Mineral nutrients.

Mineral Key Function(s) Problems of Deficiency

Calcium Bone growth and health; Muscle cramps; heart arrhythmias; blood production; muscle osteoporosis and heart function

Chloride Cell function; digestive Electrolyte imbalance function

Chromium Glucose tolerance Impaired glucose tolerance

Copper Red blood cell production Anemia

Fluorine Formation and health of Weak tooth enamel; dental caries bones and teeth (cavities); weak bones

Iodine Making thyroid hormones Goiter (enlarged thyroid gland in that support growth and neck); cretinism (a physical and metabolism mental developmental disorder);

hypothyroidism (low energy, feeling cold, dry skin, constipation); impaired fetal development

Iron Red blood cell production Anemia and related fatigue

Magnesium Bone health; heart, muscle, Muscle weakness; heart arrhyth- and nerve function; immune mias; mental changes system function

Manganese Cell function Not known

Molybdenum Cell function Heart arrhythmias

Phosphorus Bone growth and health Muscle weakness; mental changes

Potassium Cell function; muscle and Fatigue; weakness; heart nerve function arrhythmias

Selenium Cell function Fatigue; weakness

Sodium Cell function; muscle and Muscle weakness; nausea; mental nerve function changes

Zinc Child growth and Slow growth; slow wound healing; development; healthy skin diarrhea

11.4 Measuring Nutritional Status 257

11.4 MEASUltING NUTRITIONAL STKfUS

Jltl~J("(m()llTIletrv is the measurement of the human body. Height, weight, waist circumference, body fat percentage, and other measurements can be useful indicators of whether a person is underweight or overweight. They can also be used to predict some health risks. For example, having a waist circumference greater than 35 inches for a woman or 40 inches for a man is associated with an increased risk of diabetes and heart disease. 5

The m~ss index is often used to estimate the body compo- sition of adults. The BMI is calculated by taking weight kilograms and dividing it by the square of the height in meters.

weight (kg) weight (lb) BM! = = 703 X ---~-----'---'------

height (m) X height (m) height (in) X height (in)

International classification schemes generally suggest that a BMI of less than 18.5 indicates underweight, a BMI of 18.5 to 25 is in the "normal" range, a BMI of greater than 25 indicates overweight, and a BMI greater than 30 indicates obesity.6 The BMI has several limitations as a measure of health status. One is that the BMI does not consider the effect of body fat, so people who are trim but have a lot of muscle mass may be incorrectly clas- sified as overweight. BMI also does not measure physical fitness levels, and people with "normal" weights may have poor cardiovascular endurance.

For children, the more accurate measures of healthy growth are weight- for-height, weight-for-age, and height-for-age. Additional measures, such as a child's arm circumference-for-age (the mid-upper arm circumference, or MUAC) and the child's head circumference-for-age, can also be useful for assessing growth. 7 Global growth standards for children from birth through 60 months are provided by the W orId Health Organization. 8 These growth charts can be used worldwide because scientific evidence shows that infants and children from geographically diverse regions experience very similar growth patterns when their health and nutritional needs are met. 9 However, one limitation of many growth standards for children is that they require caregivers to know the birth date of the child, and many children born at home or orphaned do not have a record of this dateo When this information is not available, it can be difficult to determine if a child is growing well.

11~:3 shows a sample weight-for-age chart for girls. The graph has age (in months) on the x-axis and weight (in pounds) on the y-axis. The graph allows a parent or healthcare worker to easily determine if a child of a particular age is underweight (below the 15th percentile) or severely

258 CHAPTER 11 GLOBAL NUTRITION

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en 40 ""0 c ::J 0

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Figure 11-3 A sample child growth chart showing weight-for-age for girls from birth to age 5.

Source: Data for growth standards and percentile curves from WHO Child Growth Standards. Lengthlheight-for-age, weight-far-age, weight-far-length, weight-far-height and body mass index-far-age: methods and development. Geneva: WHO; 2006.

underweight (under the 3rd percentile) for his or her age. The sample curve for "Child 1" shows a child of healthy weight. The sample curve for "Child 2" shows an underweight child. Both children lost weight just before their second birthdays, probably due to diarrheal disease. For "Child 1," this was a minor event that barely influenced her growth. For "Child 2," this bout of diarrhea pushed her into severe malnutrition and could easily have caused her death. Children should be weighed often, especially when they are very young, so that growth trends can emerge. A child like "Child 2" who loses weight or fails to gain weight needs extra medical attention.

11.5 UNDERNUTRITION

Undernutrition is malnutrition resulting from deficiencies in the amount of food or types of nutrients eaten or from poor absorption of the nutrients that have been consumed. For example, lack of protein in the diet means

11.5 Undernutrition 259

that the body does not have the amino acids it needs to repair itself, and too little fat in the diet means that fat-soluble vitamins (like vitamins A, D, and E) cannot be processed. To stay healthy, every human needs a diet that includes at least some carbohydrates, proteins, fats or oils, and a variety of vitamins and minerals. The total amount of energy, protein, and other nutrients needed by a person varies based on age, sex, body size, activity level, climate, and pregnancy and lactation status.

Many babies begin life undernourished, often as a result of their moth- ers being undernourished when they became pregnant and not taking in adequate nutritients during pregnancy. 10 babies have an increased risk of breathing problems and other potentially life- threatening difficulties during their first weeks of life, and some of these children develop long-term impairments like learning disabilities, cerebral palsy, mental retardation, and visual or hearing impairment, especially if they have a very low birth weight.!!

Undernourished children may have (low height for age) and (low weight for height). Some children develop kwashiorkor

and have ecieIHa (swelling) of the arms, legs, and face; weak muscles; and pale hair and skin. Children with kwashiorkor may maintain a moderate weight and have a swollen belly. This is not because they are "fat." Instead, their nutrient-deficient bodies are retaining fluids (causing excess body weight) and the abdominal walls are so weak that the internal organs sag out. Kwashiorkor often develops in children who have been weaned early (frequently because of the birth of a younger sibling) and have a diet high in starch but low in protein. A child who has severe protehH~nergy malnutrition (PEM) may develop a condition called mamsmus that is associated with very low weight, weakness, and the eventual shutdown of body systems. Children with marasmus look skeletal, have loose and wrinkled skin, and have too little energy to move or cry. Both marasmus and kwashiorkor increase susceptibility to infection and put children at risk for permanent disability and death. 12

Even mild and moderate undernutrition can significantly increase the risk of illness and death due to diarrhea, acute respiratory infections, malaria, and measles. 13 At least one in five deaths of under-5 children can be attributed to undernutrition.!4 To reduce the risk of mortality, children with severe acute mabmtrition often require inpatient hospital care or intensive outpatient care as they receive therapeutic nutrition in the form of energy-dense, nutrient-enriched food (sometimes called "ready-to-use therapeutic food," or RUTF) and treatment for co-morbid infections. 15

260 CHAPTER 11 GLOBAL NUTRITION

The statistics on childhood hunger are very concerning. About 42% of children in South Asia, 20% in sub-Saharan Africa, 11 % in the Middle East and North Africa, and 10% in East Asia and the Pacific are moderately or severely underweight. 16 In total, more than 100 million children under 5 years of age worldwide are underweight 17 including nearly 80 million children in Asia and 30 million in Africa, 14

Undernutrition is closely associated with poverty. Poor children are much more likely than rich children to be underweight, and poverty cre- ates a cycle of malnutrition and infectious disease that is hard to break. This can have long-term consequences. Adults who were undernourished as children tend to be shorter, less educated, less economically productive, and more likely to have LBW babies than adults who were not underfed in childhood. 18 And adults with reduced nutritional status, especially older adults, are at risk of decreased productivity and functioning, which can have a further negative effect on their children and families. 19

11.6

Food security exists when a household, or a larger population, has access to enough food that its residents can be healthy and productive at all times. Access to food means that individuals and households are able to pro- duce, purchase, or otherwise acquire an adequate quantity, quality, and variety of food during the entire year. 20 In other words, food security is about the distribution and affordability of food as much as it is about food production. Residents of lower-income countries tend to spend a higher proportion of their incomes on food than those who live in higher-income countries 21 Similarly, low-income households within a country usually spend a higher proportion of their resources on food than richer families do,22 but they may still not be able to access enough safe, nutrient-rich food.23

Although some food insecurity issues are caused by natural and human- itarian disasters, most food insecurity is the result of chronic poverty. Households may experience long-term food insecurity, or they may have seasonal insecurity between growing seasons or during periods of under- employment or illness. Food insecurity exists in both low-income and high-income countries. For example, in the United States about 14.5% of households were food insecure at some point during 2010. 24 Many rural areas and low-income urban areas in the United States are said to be

deserts with very limited access to healthy food,zs Members of food

o Missing data <5%

5-14.9%

IiJ 15-24.9% II "":25%

11 -4,\ Percent of under-5 children who are underweight.

Source: Data from WHO global database on child growth and malnutrition. Geneva: WHO.

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262 CHAPTER 11 GLOBAL NUTRITION

100%~--------------------------------------------,

80%+-------------------------------------------~

60%+-------------------------------------------~

40% -1------------------------

20%+----

0% USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 11-5 Proportion of total household spending used for food between 2006 and 2008

Source: Data from Food security statistics by country. Rome: FAO; 2010 October.

insecure households may report feeling hungry but not eating, worrying that their food will run out, running out of food and not having enough money to buy more, eating only a limited variety of low-cost foods, cutting the size of meals, skipping meals, and not eating for a whole day.26

During times of widespread hunger or famine, a large proportion.of a population has very low food security for an extended period of time, often leading to mass migration and death. Famines are partially attributable to demographics (such as population growth) and environmental factors (such as drought), but are also due to economic and political situations. Food shortages may occur because of reduced food production, but they also happen because of increased food prices or interruptions in the food supply chain that transports food from producers to consumers. To quote Amartya Sen, a Nobel Prize-winning economist from India, "starvation is a matter of some people not having enough food to eat, and not a matter of there being not enough food to eat.',27

As the world population increases and available croplands shrink, crop yields will have to increase to meet demand. The best way to ensure that everyone is food secure is to increase food production while also increas- ing environmental protection. 28 This means developing new agricultural techniques or choosing to use time-tested techniques such as crop rota- tion that cause as little damage to the environment as possible and also

11.7 Micronutrient Deficiencies 263

increase yields. Food supplies can be further maximized when as little food as possible is wasted, eaten by animals, or allowed to spoil during transportation and storage. Food distribution systems need to be strength- ened so that those who are unable to produce enough food for their families have access to surplus food produced by others. Additionally, trade policies that make it attractive for growers to produce crops for local consumption rather than export may also help alleviate hunger. 29

Good nutrition requires more than just sufficient caloric intake. It also requires a balanced diet that includes all the essential micronutrients. Vitamin and mineral deficiencies are a common form of undernutrition in both children and adults. A large proportion of the world's population is at risk of iron, iodine, vitamin A, and zinc deficiencies. Most people with severe micronutrient deficiencies live in developing countries, but there are also pockets of micronutrient deficiencies in some high-income populations because of dietary habits.

Some vitamin deficiencies have relatively immediate symptoms. A per- son with too little niacin, which is important for metabolism, will develop

and have his or her skin darken and slough off. A person with too little riboflavin will develop rough skin and cracked lips. Thiamine defi- ciency causes which can damage the heart and nervous system. Too little vitamin C causes scurvy, which is characterized by bleeding gums and swollen, painful joints, and decreased immune system function.

Other vitamin and mineral deficiencies have long-term consequences. Adolescents who consume too little calcium are at risk for developing osteoporosis as they age, and porous bones can lead to hip fractures and other life-threatening injuries later in life. Bone strength is also reliant upon sufficient vitamin D. Vitamin D deficiency in children whose bones are still growing is called (or, more informally, "knock knees"). Vitamin D deficiency in adults whose bones have stopped growing is called and can make the bones soft and prone to breaking. Vitamin D, the "sun vitamin," can be made in the skin if it is exposed to sunlight for about 15 minutes daily, but deficiency is a problem in parts of the world where women are expected to cover themselves in public, in people who work indoors all day and avoid sun exposure, and seasonally among people who live far from the equator and have months of darkness each year. 30

264 CHAPTER 11 GLOBAL NUTRITION

Vitamin A is one of the most common causes of pre- Vision problems associated with V AD are

related to severe dry eye which can progress from night blindness and Bitot's spots (dry patches on the white of the eye) to ulcer- ation and scarring of the cornea (keratomalacia) and then complete blind- ness. Worldwide, about 190 million under-5 children (one-third of children living in countries with a per capita annual GDP less than $15,000) and 20 million pregnant women (about 15 % of pregnant women in those countries) have VAD?2 About 5 million under-5 children H~6)-or nearly 1 % of preschool-age children in low- and middle-income countries-and 10 million pregnant women (about 8% of pregnant women in those coun- tries) have VAD-associated night blindness. 32 Vitamin A also supports the body's immune system in fighting infections, and VAD increases the risk of dying from measles, diarrhea, and other causes,33,34

Yellow, orange, and dark green vegetables are the best dietary sources of vitamin A (in addition to some animal sources, such as liver). Because vitamin A is fat soluble and will only be absorbed by the body if it is eaten with fats or oils, dietary prevention of V AD requires a consistent source of both vegetables and oil. In some countries, milk, sugar, or other com- mercial products are fortified with vitamin A, but fortified foods are not

3%+-----------------------

2%+---------------------------------------~

1%+------------------------------------

USA South Poland Brazil China India Kenya Sierra Korea Leone

Figure 11-,6 Proportion of preschool children with night blindness due to vitamin A deficiency between 1995 and 2005.

Source: Data from Global prevalence of vitamin A deficiency in populations at risk

1995-2005: WHO global database on vitamin A deficiency. Geneva: WHO; 2009.

11.7 Micronutrient Deficiencies 265

available to all households that need them. Oil-filled vitamin A capsule supplements are relatively inexpensive and have prevented hundreds of thousands of child deaths and many cases of blindness,35 but distribu- tion can be a challenge, especially because the benefits of the capsules only last for 4 to 6 months. Some high-tech options are also available or in development. For example, "golden rice" is a genetically modified organism (GMO) that has been altered to produce the vitamin A precursor beta-carotene. 36 Golden rice is not yet widely used, in part because of concerns by some countries about allowing GMO products to be grown, but the manufacturer grants free licenses to low-income growers and humanitarian organizations. 37

Iodine are among the most common causes of impaired cognitive function in the world. 38 The thyroid gland, located in the neck, controls body (the rate at which a person's body uses energy) and assists with growth. Thyroid hormones (chemical mes- sengers that control metabolism) are made from the mineral iodine. If there is too little iodine in the diet, there is not enough iodine in the blood for the thyroid gland to function properly. In response, the thyroid gland will enlarge as it tries to collect more iodine from the blood, and it will produce a (a swollen neck resulting from an enlarged thyroid gland). A person who cannot produce enough thyroid hormones will have a low metabolism and will feel cold, tired, and apathetic. Babies born to mothers who have hypothyroidism may be stillborn or be born with a type of brain damage called Adults and children who are iodine deficient often suffer from impaired mental function. About 30% of the world's population is estimated to have insufficient iodine intake?9 Iodized salt is a cost-efficient way to reduce IDD, but only about two-thirds of the world's popUlation is covered, and commercial salt may not reach the neediest households. 40

Red blood cells (RBCs) carry oxygen from the lungs to the rest of the cells in the body. A molecule called hemoglobin holds the oxygen inside the RBCs, and hemoglobin is made from iron. A person with

, 266 CHAPTER 1 GLOBAL NUTRITION

too little iron is not able to make enough RBCs to efficiently transport oxygen. Symptoms of anem:!£! include pale skin, fatigue, weakness, shortness of breath, headaches, an increased heart rate, and a limited ability to concentrate at work or school. When an insufficient number of RBCs is due to inadequate iron intake, this condition is called iron U,""H-"~"-"'-S aneluia (Other forms of anemia may be due to vitamin B 12 or folic acid deficiency, blood loss, inadequate production of RBCs, or infections that destroy RBCs.)

IDA is the most common nutritional disorder in the world, affecting about 25% of the world's population (about 1.6 billion people), including about 50% of under-5 children 40% of pregnant women, and 30% of nonpregnant women. Children, pregnant women, and women who menstruate are at high risk for IDA. Children need extra iron as their body grows and their blood volume increases, pregnant women need extra iron as their blood volume expands and to reduce the risk of dying during childbirth,43 and menstruating women and those who have recently given birth may have depleted RBCs and iron from blood loss.

IDA can be prevented and treated through increased iron intake. Iron is found in both plant and animal sources. Heme iron is found in blood and meat from animals, birds, and fish, and about 15% to 35% is absorbed by the body; nonheme iron is found in plants, eggs, and milk,

100%,-------------------------------------------~

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60%+---------------------------~

40% +------------------

20% +---------------{~

0% +--"""''''----,-- USA South Poland Brazil China India Kenya Sierra

Korea Leone

Proportion of preschool children with anemia (Hb < 1 00 gIL) in 2006.

Source: Data from de Benoist B, McLean Erin, Egli I, Cogswell, editors. Worldwide prevalence of anaemia 1993-2005. Geneva: WHO; 2008.

11.7 Micronutrient Deficiencies 267

and less than 5% is absorbed. 44 Iron can also be taken as a supplement or added to fortified foods like pastas and flourS. 45 Control of infections that cause internal bleeding (like hookworm, whipworm, and schisto- somiasis) or destruction of RBCs (like malaria) is also important for preventing and treating IDA.

Zinc is important for immune function, growth, and child development. Any level of zinc deficiency can increase susceptibility to infection and increase the risk of death from diarrhea, malaria, and pneumonia. Several hundred thousand under-5 child deaths from these infections could poten- tially be prevented each year by reducing zinc deficiency in Africa and Asia.46 Zinc is found primarily in animal sources, so people who consume a mostly plant-based diet often benefit from taking zinc supplements or eating food fortified with zinc.

11.7,E

The best way to consume micro nutrients is through food. When a person's diet does not provide enough nutrients or the body is not absorbing enough of the nutrients, nonfood sources may be help- ful 11~3).47 Micronutrient deficiencies in a population can sometimes be prevented by providing su.pplements such as multivita- min pills or by enriching or fortifying food with extra micronutrients. A food is when some of the vitamins and minerals lost during processing are added back into the food. A fodifi.ed food has nutrients that are not naturally present in the ingredients added to the product. Common examples of enriched and fortified foods include vitamin A fortified sugar, folic acid and iron-enriched flours, and iodized salt. However, supplements and enriched and fortified foods may not pro- vide vitamins and minerals in a form that has a high bioavailability.

is the fraction of the vitamin or mineral consumed that is able to be absorbed and used by the body. Absorption can be increased by taking supplements with food. For example, fat-soluble vitamins must be taken with fat or oil, and iron absorption is boosted by vitamin C.

268 CHAPTER 11 GLOBAL NUTRITION

Table 11-3 Preventive and treatment interventions for maternal and child undernutrition.

Preventive Interventions (Primary Prevention)

Treatment Interventions (Secondary Prevention)

• Improved dietary intake of pregnant • Treatment and monitoring of and lactating women severely malnourished children

• Exclusive breastfeeding for 6 months

• Appropriate complementary child feeding for 6- to 24-month-old children

• Iron and folic acid supplementation for children to prevent anemia

• Vitamin A supplementation for pregnant women and children

• Antihelminthic treatment of school- age children to prevent anemia

• Improved hygiene and sanitation to prevent diarrhea

• High-dose treatment of clinical signs of vitamin A deficiency

• Appropriate feeding of sick children

• Oral rehydration therapy (ORT)

• Timely treatment of infectious and parasitic diseases

Source: Information from Jamison DT, Breman JG, Measham AR, et aI., editors. Disease control priorities in developing countries, 2nd edition. Washington DC: Oxford University Press and IBRDlWorid Bank; 2006.

11.8 OVERWEIGHT AND OBESITY

Overnutrition is a form of malnutrition caused by excessive intake of calories and nutrients. The average adult needs about 1800 kilocalories each day, with additional calories required for physical activity (and, if applicable, for pregnancy and lactation).48 A person who consistently takes in more calories than the body uses will gain extra weight, become overweight, and then develop obesity (Figures 11-8 and 11-9). Obesity is associated with an increased risk for many diseases, including type 2 dia- betes, hypertension (high blood pressure), heart disease, strokes, gallstones and other digestive disorders, back pain, arthritis of the back and hip, and several types of cancer.49

Overnutrition has become a concern in nearly every region of the world. Even in regions where undernutrition is still a serious problem, there are

D No data 1500-2299

2300-2749

2750-3199

3200-3800

H-8 Dietary energy supply (kilocalories per person per day) in 2006.

Source: Data from Food and Agriculture Organization (FAO) of the United Nations. FAO statistical yearbook 2012. Rome: FAO; 2012. Table 16: Dietary energy supplies and changes in dietary composition.

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270 CHAPTER 11 GLOBAL NUTRITION

4000~------------------------------------------.

3500

3000

2500

2000

1500

1000

500

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 11-9 Dietary energy supply (kilocalories per person per day) between 2006 and 2008.

Source: Data from Food security statistics by country. Rome: FAO; 2010 October.

pockets of obesity, especially in high-income urban areas and among women.50 In 2005, about 23% of adults worldwide were overweight or obese (Figures 11-10 and 11_11).51-53 The global prevalence of adult obe- sity increased from about 5% of men and 8% of women in 1980 to about 10% of men and 14% of women in 2008.54 But obesity is not just a condi- tion of adulthood. In 2010, about 12% of under-5 children in developed countries and 6% of children in developing countries were overweight or obese.55 The prevalence of overweight and obesity among children less than 5 years old worldwide increased from about 4% in 1990 to about 7% in 2010, and is projected to reach 9% by 2020.55 The rate of overweight and obesity is also increasing significantly among school-aged children in nearly every region in the world.56

Genes influence metabolic rate, body shape (where a person carries excess weight), and the efficiency of the body at storing extra calories, but genetic change does not explain why obesity has become so much more prevalent in the past decade. It takes generations for genetic adaptation to occur, but it takes only a short time to change dietary and exercise habits. Thus, nutri- tional status is a function of biology and also of psychology and sociology. Nutritional science studies that use laboratory tests to quantify the amount of calories and types of nutrients in foods only explain part of the rise in obesity and other forms of malnutrition. These studies must be complemented by examinations of food preparation and eating habits and evaluations of the

.~,

D Missing 0-4.9%

5.0-14.9%

15.0-24.9%

H-l0 Prevalence of obesity (EMI 2': 30) in adults ages 15 and older in 2005.

Source: Data from WHO GloballnfoBase. Geneva: WHO.

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272 CHAPTER 11 GLOBAL NUTRITION

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o USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 11-11 Mean age-standardized body mass index (BMI) of male and female adults ages 20 and older in 2008.

Source: Data from Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group. Country trends in metabolic risk factors. London: Imperial College London; 2011.

cultural and social aspects of eating, as these factors are significant contribu- tors to the rising prevalence of obesity around the world.

Individuals and families who seek to reach and maintain target weights must adopt and sustain healthy behaviors. At the population level, policies that promote healthy diets and physical activity, such as health information campaigns, limits on the marketing of unhealthy food to children, taxes to increase the price of unhealthy foods, subsidies to lower the cost of healthy foods, and regulations that improve the nutrition information provided on food packages, may help prevent and reduce obesity.57

11.9 DISCUSSION QUESTIONS

1. What components of your diet are sources of essential nutrients like carbohydrates, proteins, fats, vitamins, and minerals? Do you get more or less than the recommended amounts in each category?

2. Design a one-day menu plan that provides healthy amounts of macro- nutrients, micronutrients, and energy.

3. Do you take vitamin and mineral supplements? Why or why not?

References 273

4. What governmental agencies and nongovernmental organizations in your community work to address issues of local hunger and food insecurity?

5. Do you agree that there is enough food for everyone in the world to have a healthy diet? What steps can be taken to reduce the burden caused by hunger?

6. Compare and contrast the health consequences of undernutrition and overnutrition.

RE:!i'ERENCES

1. Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington DC: The National Academies Press; 2005.

2. Food and Agriculture Organization (FAO) of the United Nations. FAO statistical yearbook 2012. Rome: FAO; 2012. Table 16: Dietary energy supplies and changes in dietary composition.

3. Hu FB, Willett We. Optimal diets for prevention of coronary heart disease. lAMA. 2002;288:2569-2578.

4. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbo- hydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apoli- poproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003;77: 1146-1155.

5. Klein S, Allison DB, Heymsfield SB, et a1. Waist circumference and cardiometa- bolic risk: a consensus statement from Shaping America's Health: Association for Weight Management and Obesity Prevention; NAASO, The Obesity Society; the American Society for Nutrition; and the American Diabetes Association. Am J Clin Nutr.2007;85:1197-1202.

6. Obesity: preventing and managing the global epidemic. Geneva: WHO; 2000. 7. WHO Child Growth Standards. Methods and development: head circumference-for-age,

arm circumference-for-age, triceps skinfold-for-age and subscapular skinfold-for-age. Geneva: WHO; 2007.

8. WHO Child Growth Standards. Lengthlheight-for-age, weight-for-age, weight-for- length, weight-for-height and body mass index-far-age: methods and development. Geneva: WHO; 2006.

9. Onyango AW, de Onis M, Caroli M, et a1. Field-testing the WHO Child Growth Standards in four countries. J Nutr. 2007;137: 149-152.

10. Kramer MS. Determinants of low birth weight: methodological assessment and meta- analysis. Bull World Health Organ. 1987;65:663-737.

11. Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008;371 :261-269.

12. Waterlow IC. Classification and definition of protein-calorie malnutrition. Br Med l. 1972;3:566-569.

13. Caulfield LE, de Onis M, Blossner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nut. 2004;80:193-198.

274 CHAPTER 11 GLOBAL NUTRITION

14. Black RE, Allen LH, Bhutta ZA, et al.; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-260.

15. Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe acute malnutrition in children. Lancet. 2006;368:1992-2000.

16. State of the world's children 2012. New York: UNICEF; 2012. 17. WHO global database on child growth and malnutrition. Geneva: WHO. 18. Victora CG, Adair L, Fall C, et al.; Maternal and Child Undernutrition Study Group.

Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371:340-357.

19. Chilima D. Assessing nutritional status and functional ability of older adults in developing countries. Dev Pract. 2000;10:108-113.

20. Barrett CB. Measuring food insecurity. Science. 2010;327:825-828. 21. Food security statistics by country. Rome: FAO; 2010. 22. Kaufman PR, MacDonald JM, Lutz SM, Smallwood DM. Do the poor pay more

for food? Item selection and price differences affect low-income household food costs (Agricultural Economic Report No. 759). Washington DC: U.S. Department of Agriculture (USDA); 1997.

23. Melgar-Quinonez HR, Zubieta AC, MkNelly B, Nteziyaremye A, Gerardo MFD, Dunford C. Household food insecurity and food expenditure in Bolivia, Burkina Faso, and the Philippines. f Nutr. 2006;136: 1431S-1437S.

24. Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household Food Security in the United States in 2010 (ERR-125). Washington DC: USDA; 2011.

25. BeaulacI, Kristjansson E, Cummins S. A systematic review offood deserts, 1966-2007. Prev Chronic Dis. 2009;6:A105.

26. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measuring householdfood security. Alexandria VA: USDA; 2000.

27. Sen A. Ingredients of famine analysis: availability and entitlements. Q f Econ. 1981 ;96:433-464.

28. Godfray HCJ, Beddington JR, Crute IR, et al. Food security: the challenge of feeding 9 billion people. Science. 2010;327:812-818.

29. Maxwell S, Slater R. Food policy old and new. Dev Policy Rev. 2003;21 :531-553. 30. Holick ME Vitamin D deficiency. New Engl f Med. 2007;357:266-281. 31. Gilbert C, Muhit M. Twenty years of childhood blindness: what have we learnt?

Community Eye Health. 2008;21:46-47. 32. Global prevalence of vitamin A deficiency in populations at risk 1995-2005: WHO

global database on vitamin A deficiency. Geneva: WHO; 2009. 33. Fawzi WW, Chalmers TC, Herrera MG, Mosteller E Vitamin A supplementation and

child mortality: a meta-analysis. fAMA. 1993;269:898-903. 34. Glasziou PP, Mackerras DE. Vitamin A supplementation in infectious diseases: a

meta-analysis. BMf. 1993;306:366-370. 35. Mayo-Wilson E, Imdad A, Herzer K, Yakoob MY, Bhutta ZA. Vitamin A supplements

for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. BMf. 2011;343:d5094.

36. Tang G, Qin J, Dolnikowski GG, Russell RM, Grusak MA. Golden rice is an effective source of vitamin A. Am f Clin Nutr. 2009;89:1176-1783.

37. Enserink M. Tough lessons from golden rice. Science. 2008;320:468-471.

References 275

38. Zimmermann MB, Jooste PL, Pandav CS. Iodine-deficiency disorders. Lancet. 2008;372: 1251-1262.

39. Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2012 and trends over the past decade. J Nutr. 2012;142:744-750.

40. Andersson M, de Benoist B, Rogers L. Epidemiology of iodine deficiency: salt iodisa- tion and iodine status. Best Pract Res Clin Endocrinol Metab. 2010;24: 1-11.

41. McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993-2005. Public Health Nutr. 2009;12:444-454.

42. de Benoist B, McLean Erin, Egli I, Cogswell, editors. Worldwide prevalence of anaemia 1993-2005. Geneva: WHO; 2008.

43. Brabin BJ, Hakimi M, Belletier D. An analysis of anemia and pregnancy-related mater- nal mortality. J Nutr. 2001;131(2S-2):604S-614S.

44. Zimmermann MB, Hurrell RF. Nutritional iron deficiency. Lancet. 2007;370: 511-520.

45. Hurrell RF. How to ensure adequate iron absorption from iron-fortified food. Nutr Rev. 2002;60:S7-15.

46. Fischer Walker CL, Ezzati M, Black RE. Global and regional child mortality and burden of disease attributable to zinc deficiency. Eur J Clin Nutr. 2009;63:591-597.

47. Jamison DT, Breman JG, Measham AR, et a!., editors. Disease control priorities in developing countries, 2nd edition. Washington DC: Oxford University Press and IBRDI World Bank; 2006.

48. Pellett PL. Food energy requirements in humans. Am J Clin Nutr. 1991;51:711-722. 49. Field AE, Coakley EH, Must A, Spadano JL, Laird N, Dietz WH, Rimm E, Colditz

GA. Impact of overweight on the risk of developing common chronic diseases during a lD-year period. Arch Intern Med. 2001;161:1581-1586.

50. Monteiro CA, Moura EC, Conde WL, Popkin BM. Socioeconomic status and obesity in adult populations of developing countries: a review. Bull World Health Organ. 2004: 82:940-946.

51. Kelly T, Yang W, Chen CS, Reynolds K, He J. Global burden of obesity in 2005 and projections to 2030. Int J Obesity. 2008;32:1431-1437.

52. WHO Global InfoBase. Geneva: WHO. 53. Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating

Group. Country trends in metabolic risk factors. London: Imperial College London; 201l.

54. Finucane MM, Stevens GA, Cowan MJ, et al.; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Body Mass Index). National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011 ;377:557-567.

55. de Onis M, BlOssner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92:1257-1264.

56. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes. 2006; 1: 11-25.

57. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet. 2010;376: 1775-1784.

HEALTH

A heaUh consists of all of the people, policies, and programs that work to promote health and prevent disease in a country. The World Health Organization (WHO) has identified six core building blocks of,health systems:

1. The provision of effective personal and population-based healthcare services;

2. A well-trained and productive health workforce that is able to provide quality care to all populations;

3. Access to essential medicines, vaccines, and health technologies; 4. A strong health information system that collects data about health

systems performance; 5. A health financing system that enables everyone to access afford-

able needed services and at the same time provides incentives not to overuse services; and

6. Effective oversight of the system to ensure safety, efficiency, and accountability. 1

The goals of health systems include improving the health of populations being served; being responsive to the expectations patients and their families have about dignity, privacy, quality, and choice; ,ensuring a fair

277

278 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

Source of Funds 1':J·'3A"'nvatE~'3·

Payment

Cost Burden

Coverage

Where Used

Figure 12-1 Public and private approaches to healthcare funding and coverage. Source: Adapted from World health report 1999. Geneva: WHO; 1999. Figure 3.5.

financial contribution from users that does not overly burden the poor; and improving the efficiency of the system.2

Some countries have a healthcare system in which the medical care of individuals is usually privately funded through health insurance or the personal funds of the individual and his or her family. Others sponsor a publicly funded healthcare system that is paid for with tax revenue. Some systems pay for personal health with a combination of public and private sources (Figure 12-1).3

Most high-income countries have a government-sponsored healthcare system that is paid for through general tax revenue or through a government- run social insurance system (sometimes called a sickness fund). For example, the Republic of Korea's National Health Insurance Corporation (NHIC) and Poland's National Health Fund (NFZ) pay for nearly all health care in those countries. Health services in countries with single-payer health systems may be delivered by public or private providers. In Poland most healthcare services are provided at public facilities by clinicians who are government employees,4 but in South Korea most services are paid for by the government but provided by private hospitals, clinics, and health centers. 5

12.1 Health Systems 279

The services covered by universal healthcare plans and the prices for these services vary for different systems. Only some systems cover dental care and vision care. Some systems require users to pay a small fee at the time of service or a small amount for prescription medications; some do not. Some pay for all the expenses of hospitalization, while others require the patient to pay part of the cost of a hospital stay. Some allow users a choice of what types of services they want to access and how much they want to pay for them. For example, South Korean patients pay a fee if they select premium care (such as a private hospital room rather than a multibed ward) or want medical services not covered as part of the NHIC benefits package. 5 Supplemental private insurance can be purchased to pay for services not covered by the national health plan. In Brazil, everyone is entitled to free basic and advanced health care, but about one-quarter of people supplement the government health plan with private health insurance that enables them to access specialized and elective services. 6

Common complaints about publicly funded health care include the overuse of health resources by consumers (because they do not pay directly for services) and long waiting times for access to specialislis and advanced procedures. 7 However, universal healthcare systems increase equity in access to health services and improve the efficiency of the health system by reducing the underuse of health services by the poor, which in the long term saves on overall healthcare costs. 8 Single-payer systems also benefit from the streamlining of administrative and billing processes. 8

The United States is one of the few developed countries that does not have a universal public healthcare system. The United States relies primarily on private health insurance and private healthcare providers. However, the government sponsors Medicare for the elderly and disabled and Medicaid for the country's poorest citizens, provides care to injured veterans through the Veterans Administration (V A) hospital system, and provides health care to indigenous Americans through the Indian Health Service (IHS).

Health insurance systems, whether private or public, are funded based on the principle of pooled risk. PooleiR risk assumes that if many low-risk people and a few high-risk people all pay premiums to the insurance system over many years, then there will be a pot of money that· can be used to pay for major illnesses when they occur. Only a few people will suf- fer a catastrophic injury or develop a very serious chronic condition, but because everyone is at risk for serious illness most people are willing to pay additional taxes or purchase insurance that protects them against the

280 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

possibility of incurring an overwhelming amount of debt due to medi- cal bills. (Pooled risk is at the core of the U.S. Patient Protection and Affordable Care Act of 2010, which makes participation in an insurance plan mandatory for those who can afford it and supplements the purchase of a private plan by those with lower incomes who do not quality for government-sponsored plans. 9)

The services provided by private health insurance companies vary greatly, just as the services provided by government plans do. Some low-cost insurance plans only cover conditions serious enough to require hospitalization. Higher-cost insurance plans may cover clinic visits, preventive care, and medications in addition to paying for hospitaliza- tions and surgeries. In some countries, private insurance companies charge higher premiums to people with preexisting conditions, older people, and people who are in high-risk groups, and the companies have the option of denying coverage to people who have applied to be insured. These practices can prevent lower-income individuals and families from accessing health insurance, and that may put them at risk of bankruptcy if a serious illness or injury occurs.

In most low-income countries, a mix of public, not -for-profit private, and for-profit formal and informal healthcare providers are available in urban areas,lO but there may be very few services in rural areas. Most healthcare services are paid for out-of-pocket on a pay-as-you-go basis. This means that many people who would like to access health care cannot do so because of the cost. For example, in India and Kenya the user fees that are assessed by both public and private providers at the time of service are costly for low-income households. 11,12 In Sierra Leone, free care at government facili- ties was introduced, in 2011, for pregnant women, breastfeeding mothers, and children younger than 5 years old.13 However, access to health care is still limited for older children, men, and women who are not childbearing. Increasing access to affordable health services for the most vulnerable populations is one of the goals for healthcare systems in most low-income countries.

12.2 PERSONAL HEALTH CARE COSTS

Countries vary both by the type of health financing system they use and by the amount of money that is spent on health care (Table 12-1). High-income countries generally spend more on health care per person and more on health

Table 12-1 Health expenditures in 2009.

South Sierra Country USA Korea Poland Brazil China India Kenya Leone

Per capital total expenditure on health (PPP international $) 7960 1879 1391 921 347 124 75 110

Per capita government expenditure on health 3795 1093 1006 401 182 38 33 12 (PPP international $) ........

Government expenditure on health as a % of total 47.7 58.2 72.3 43.6 52.5 30.3 43.3 10.5 ~ N

expenditure on health ""t:l ~

Total spending on health care (in $U.S. billions) (in 2010) 2584 70 35 193 298 66 1.5 0.25 ~ c ~ ~

Total (public and private) expenditure on health as % of 17.6 6.9 7.4 8.8 5.1 4.2 4.8 13.9 ......

gross domestic product (GOP) ~ ~ ......

Government expenditure on health as % of total 19.6 12.2 11.9 5.9 12.1 3.7 7.3 6.4 ~ ("") government expenditure ~

Source: Data from Health system financing profile by country. Geneva: WHO Global Health Expenditure Database; 2010; and ~ '" World health statistics 2012. Geneva: WHO; 2012. i:l'

N 00 .....

282 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

8000

7000 400~----------------------------~

6000 --;::::::======j 300 5000 200

4000 IJI Government

spending 100

3000 o 2000

1000

0 USA South Poland Brazil

Korea China India Kenya Sierra

Figure 12-2 Total expenditure on health per capita in U.S.$ in 2009. Source: Data from World health statistics 2012. Geneva: WHO; 2012.

Leone

care as a percentage of gross domestic product (GDP) than low-income countries. Additionally, the governments of high-income countries tend to pay for a higher percentage of health care costs than lower-income countries pay (Figure 12-2).14,15 However, just as the types of health systems vary within one geographic region or one income group, there are variations in which entities pay for health care in different countries within regions and income brackets.

The countries with the least total spending on health generally require the greatest amount of personal health spending, both as a propor- tion of the healthcare bill and as a proportion of household income. 16 People who live in low-income countries must often pay for the major- ity of their health care themselves out-of-pocket at the time of service (Figure 12_3).15 Because many residents of low-income countries have very little income, many households have a very limited ability to pur- chase healthcare services. An illness can quickly bankrupt a family. The poorest people might not have access to any health care at all because they cannot pay for it.

Even though access to health care is limited for many people around the world, health care is a huge part of the global economy. Worldwide, more than $4 trillion is spent on health each year, and those costs are rising. 14

12.3 Paying for Global Public Health 283

IllI Out-of-pocket private spending

IllI Private prepaid plans (private insurance)

o Other private spending

o Social security !!I General government

spending (including external aid)

12<5 Expenditure on health by governmental (including external aid) and private sources (out-of-pocket spending and private insurance) in 2009.

Source: Data from World health statistics 2012. Geneva: WHO; 2012,

V!'"JUI1'v HEALTH

Payment for health can be divided into two categories: money spent on personal health and money spent on public health. Personal health expenses relate to the health of one individual or family, such as the cost of purchasing chloroquine to treat a case of malaria, buying test strips for self-monitoring of blood glucose levels by those with diabetes, or paying for a midwife to help deliver a baby. Public health expenses relate to shared activities that protect a community or a country or the global population at large, such as the marketing of mass polio vaccination days, the use of molluscicides to kill the snails in a schistosomiasis-infected lake, or the development and test- ing of a new antibiotic. The money spent on local and global public health initiatives comes from somewhat different sources than the money that pays for individual health care. In addition to local and national governmental spending, global public health is funded by a combination of grants from one country to another, loans from intergovernmental agencies, and gifts from private-sector foundations, businesses, and individuals.

Donors have a variety of motivations for giving.!7 The governments of high-income countries may see providing health funding for lower-income countries as a foreign policy strategy that helps build trade alliances or as

284 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

a security measure that helps protect the homeland. 18,19 Lending agencies may consider global health to be a financial investment. Philanthropic organizations may view global health as a tool for reducing poverty. Disease-specific charities may be able to increase their effectiveness by addressing concerns worldwide instead of limiting their work to a single country or region. Most of these rationales for funding global health involve benefits for the donors, the recipients, and the global population. Global health funding is about more than the global rich aiding the global poor. Global health funding is about using resources to address shared health concerns and achieve mutual goals.

12.3.A Local and National Government Funds

The majority of local and national public health initiatives around the world are paid for by taxes collected by the governments providing those services (Figure 12-4).14 This is true for both developed and developing countries. Domestic spending on health significantly increased even in low- and middle-income countries between the 1990s and the 201Os. 20,21 In general, this increase has been attributed to an increasing GDP, which has increased tax revenue.

100%

80%

60%

40%

20%

0% USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 12-4 Sources of funding for the health system in 2010.

• Funding from abroad

III Domestic funding

Source: Data from Health system financing profile by country. Geneva: WHO Global Health Expenditure Database; 2010.

12.3 Paying for Global Public Health 285

BHa1.eraH Slid is money given directly from one country to another. For example, the United States gives more than $10 billion each year as bilateral aid, which accounts for about one-third of total U.S. foreign aid appropriations 12_5).22 (Foreign aid is about 1 % of the U.S. national budget. Most military assistance is provided from a separate budget line.) About 21 % of total U.S. foreign aid in 2010 was devoted to health activities, up from about 5% in the late 1990s?2 In 2010, the recipients of the most U.S. bilateral aid were Afghanistan, Israel, Pakistan, Egypt, Haiti, and Iraq 22 Aid may be given in the form of equipment and commodities (such as food and computers), training (such as the education provided by Peace Corps volunteers) and expert advice, cash transfers, or economic infrastructure development (such as building schools and health clinics in postconflict areas).22

Most international aid is donated to lower-income countries by high-income countries that are members of the Development Assistance Committee (DAC) of the Organisation for Economic Co-operation and Development (OEeD). More than $20 billion in direct aid specifically for health and health-related activi- ties is donated by high-income countries to low- and middle-income countries each year, via bilateral aid or donations made through United Nations (UN)

Civilian security aid 9%

Political/strategic aid 25%

Military aid 12%

Multilateral aid 7%

12--5 Types of U.S. foreign aid, fiscal year 2010.

34%

13%

Source: Data from Tamoff C, Lawson ML. Foreign aid: an introduction to U.S. programs and policy. Washington DC: Congressional Research Service; 2011.

286 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

East Asia, 3%

Central and South America,

13%

Sub-Saharan Africa, 29%

South & Central Asia, 26%

Middle East and North Africa,

26%

Figure 12-6 Recipients of U.S. foreign aid, fiscal year 2010. Source: Data from Tarnoff C, Lawson ML. Foreign aid: an introduction to U.S. programs and policy. Washington DC: Congressional Research Service; 2011.

agencies, international health partnerships, and donations to international nongovernmental organizations (Figure 12-7).23,24 The five donor nations that provide the greatest amount of official development assistance, or "ODA," are the United States, the United Kingdom, France, Germany, and Japan, which each donated more than $10 billion in 2010.25 As a percentage of their gross national income (GNI), the largest donors are Norway, Luxembourg, Sweden, Denmark, and the Netherlands, each of which donates more than 0.8% of its GNI.25 (The United States donates about 0.2% of its GNI.)

Although some aid is given simply to fight poverty, aid is often tied to the political and economic interests of the donor country. For example, bilateral food aid agreements may require food to be purchased in the donor country and shipped by donor carriers to the recipient (as is the case for U.S. food assistance22). These kinds of bilateral aid agreements sometimes pay more attention to the business interests of donor nations than to the needs of the recipient country. However, the end result is a donation of a good or service to a less-developed country.

12.3.C The World Bank and IMF

Multilateral aid is money pooled from many donors. The World Bank, International Monetary Fund, and other UN agencies are the largest mul- tilateral development funding institutions. Multilateral aid is often in the form of loans rather than gifts.

Humanitarian Aid

Multisector/ Cross-Cutting

Production Sectors (such as agriculture, mining,

construction, and tourism)

12.3 Paying Jor Global Public Health 287

Education

Econom ic I nfrastructu re and Services (such as

communciations, energy, and banking)

Population and Reproductive Health

Water Supply and Sanitation

Government and Civil Society

and Services

12--7 Distribution of total official development assistance (ODA) from OEeD countries in 2010.

Source: Data from DAC5 official bilateral commitments by sector. Paris: OEeD StatExtracts; 2012.

The two multilateral agencies most involved in offering (money that needs to be repaid and usually requires payment of interest on the money that has been loaned) and grants (money that does not have to be repaid) are the World Bank and the International Monetary Fund (IMP). Both the World Bank and the IMP were founded in 1944 during a summit held at Bretton Woods, New Hampshire, are headquartered in Washington, DC, and are "owned" by their nearly 180 member nations. But the two have distinct functions and modes of operating?6

The World Bank is an investment bank that makes loans to developing countries. Its board of governors is composed of representatives from each member country, who are usually member countries' ministers of finance (or the equivalent, such as the Secretary of the Treasury of the United States), and its president has always been a U.S. citizen. Because World Bank loans must be repaid with interest, lending nations can make a profit by lending money to poorer countries, assuming that the principal is repaid with interest.

The World Bank's primary lending institute is the International Bank for Reconstruction and Development (IBRD), which issues bonds in order to be able to make loans to middle-income member countries. These loans

288 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

carry an interest rate that is slightly above the market rate, and they are usually supposed to be repaid within 15 years. The majority of loans are for specific infrastructure projects, although funds can also be used for other economic development purposes. The International Development Association (IDA) makes loans (and provides some interest-free credit and grants) to low-income member nations using money that has been donated from high-income countries. IDA loans are usually supposed to be paid back over a 40-year period. The World Bank Group is also home to the International Finance Corporation (IFC), the Multilateral Investment Guarantee Agency (MIGA), and the International Centre for Settlement of Investment Disputes (lCSID).

The IMF provides a structure for international monetary policy and cur- rency exchanges, and it also makes loans to countries of any income level that have a "balance of payment" need and would otherwise not be able to make payments on their other international loans. The goal of IMF loans is to allow countries to rebuild their monetary reserves, stabilize their cur- rencies, continue paying for imports, and create conditions for economic growth and high employment rates. The interest rates for IMF funds are usually slightly below market rates, and money received from the IMF is usually supposed to be paid back within a few years. The IMF is funded by membership fees (called "quotas") paid by its member countries, and it operates like a credit union. The IMF's managing director has always been a European.

Both the World Bank and the IMF may require countries to adhere to a Structural Adjustment Program (SAP) as a condition for receiving a loan. (Because SAPs acquired a negative reputation, loan requirements have been softened and reformulated as Poverty Reduction Strategy Papers [PRSPs] that spell out applicant countries' plans for implementing eco- nomic reforms.) Structural adjustment and related programs frequently require the recipient to raise taxes, reduce government spending, devalue the country's currency, eliminate price controls and subsidies, and increase production of exports. SAPs (and similar programs) are often designed to encourage capitalism through privatization of government-owned utilities and industries and deregulation of markets. This can increase the wealth of the rich business owners and government officials who live in low- and middle-income countries and negotiate the terms of international loans, because the loans can be used to support their companies (and, if cor- rupt leaders redirect some funds for personal use, to increase the value of their private bank accounts). But SAPs have been criticized for creating even tougher economic situations for poor households. For example, the SAP rules may put farmers and other workers in low-income countries at

123 Paying for Global Public Health 289

a competitive disadvantage because richer nations do not have the same restrictions on farm subsidies. The short-term consequences of imple- menting SAPs often include falling incomes, decreased social service expenditures, rising food prices, and an increased burden on women who must shift from formal wage labor to informal, low-paid work as the unem- ployment rate rises.27 Additionally, there is limited evidence to support the effectiveness of SAPs. at promoting economic growth. 28

A major criticism of the intemationalloan system is that payments on debt divert money away from education, health, clean water, and other essential human services in low-income countries. Because interest rates may increase over time, the amount that must be paid each year may not decrease significantly even if the principal and interest for some loans is repaid. And because the amount that must be repaid grows larger if debt payments are not made, the level of resulting debt can burden a country and stifle economic growth for decades.

To alleviate this burden, lending nations have agreed to forgive some of the debts of the most burdened poor countries. The World Bank's Enhanced Heavily Indebted Poor Countries (HIPC) Initiative has committed to forgiv- ing billions of dollars of debt for low-income countries with unsustainable debt loads (measured by a debt-to-export ratio of more than 150%) that develop and implement PRSPs. 29 The RIPe cancellation only applies to loans from the IMF, the World Bank, and the African Development Fund; it does not apply to other bilateral and multilateral donors or private lenders. However, all of the eight large industrialized countries that make up the G8 (Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the United States) pledged in 2005 to cancel the bilateral debts of the most indebted nations. The hope is that this will allow HIPCs to put more resources toward improving their health and educational systems, which will in turn contribute to ending the cycle of poverty and poor health.

Private foundations are making an increasingly significant contribution to spending on global public health. For example, the Bill & Melinda Gates Foundation has provided more than $1 billion each year in recent years to support projects such as the development and dissemination of vaccines and medications. 30 Major recipients of these funds include the GAVI Alliance, PATH, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. 31

Groups like the Wellcome Trust (which is based in the United Kingdom), the Rockefeller Foundation, the Ford Foundation, the UN Foundation,

290 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

and the Aga Khan Foundation also make multimillion-dollar international health grants every year.32

12.3.E Businesses

Each year, pharmaceutical companies like Abbott, Allergan, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly and Company, GlaxoSmithKline, Johnson & Johnson, Novartis, Novo Nordisk, Roche, and Sanofi donate drugs and other products valued at more than $1 billion. 33

Some companies have made special investments in particular diseases. For example, Merck's Mectizan donation program has furthered progress toward onchocerciasis elimination,34 and Pfizer's donations of Zithromax, a type of antibiotic, are helping the global effort to prevent blindness due to trachoma. 35 Most of the major drug companies have programs for donation of antiretroviral drugs for HIV / AIDS, and many of the companies also make donations in the areas of tuberculosis, malaria, tropical diseases, prevent- able diseases (especially with vaccine donations), maternal and child health, chronic diseases, and/or emergency relief.36

Other types of companies also make in-kind donations and fund global health programs through their own foundations as part of their corporate social responsibility plans. For example, the Coca-Cola Foundation, PepsiCo Foundation, and Unilever Foundation all sponsor portfolios of international water and sanitation, nutrition, and education projects, and the Johnson & Johnson Family of Companies Contribution Fund maintains a portfolio of maternal and child health projects.

In addition to being a form of humanitarian aid, and often a tax deduction, these donations help develop international markets and bring brand names to new potential customers. Populations with increased incomes and decreased health expenditures as a result of successful health initiatives have more money to spend on other goods and services. By helping potential consumers become healthy and maintain their health, companies are expanding their markets.

12.3.F Personal Donations

Millions of individuals also make donations each year to global health activities. This generosity is especially visible after major disasters. The American Red Cross alone received more than $200 million in donations after the Japanese earthquake and tsunami in 2011 and nearly $300 million after the earthquake in Haiti in 2010. 37 Child sponsorship organizations like

12.3 Paying for Global Public Health 291

World Vision, Save the Children, and Compassion International are also popular recipients of charitable giving. Thousands of smaller charitable organizations rely exclusively on private donations.

Americans donated nearly $300 billion to charity in 2011, of which 73% was given by individuals (rather than foundations, bequests, or corpora- tions)?8 In total, the donations represent about 2% of disposable income in the United States. The major recipients of funding were religious bodies ($96 billion); educational institutions ($39 billion); human services organizations providing food, clothing, shelter, and other essential goods and services domestically or internationally ($35 billion); health charities, includ- ing disease-specific support organizations, research-focused groups, and healthcare providers such as clinics and hospitals ($25 billion); international affairs charities working in the areas of relief, development, and public pol- icy ($22 billion); community development organizations ($21 billion); arts and culture nonprofits ($13 billion); and environmental groups ($8 billion)

38 Thus, a high proportion of donations across these categories went toward activities related to global health. Some of the major recipients of these funds in the United States are listed in Tabftes 12r-2 and 39 As a comparison, major international health-related charities in the United Kingdom include Save the Children, OxFam, and the British Red Cross.40

Arts, Culture, and Humanities

Public-Society Benefit

International Affairs

Human Services

12"-8 Recipients of U.S. charitable giving in 2011.

Source: Data from Giving USA 2012: The annual report on philanthropy for the year 2011. Executive summary. Chicago: The Giving Institute; 2012.

292 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

Table 12-2 Major international relief and development charities based in the United States.

Annual Expenditures Program Expenditures Name (2010-2011) (2010-2011)

Feed The Children $1248 million $1161 million

World Vision $1206 million $1066 million

Food For The Poor $1051 million $1018 million

Catholic Relief Services $820 million $774 million

AmeriCares $665 million $655 million

CARE $614 million $550 million

Operation Blessing International $472 million $469 million

Save the Children $516 million $468 million

Compassion International $520 million $433 million

United States Fund for UNICEF $447 million $405 million

MAP International $402 million $399 million

Direct Relief International $309 million $306 million

Samaritan's Purse $336 million $297 million

International Rescue Committee $314 million $287 million

Catholic Medical Mission Board $283 million $277 million

Brother's Brother Foundation $274 million $274 million

Mercy Corps $267 million $232 million

PATH $257 million $225 million

The Rotary Foundation of $228 million $205 million Rotary International

The Carter Center $215 million $201 million

CHF International $219 million $198 million

Project HOPE $202 million $190 million

Food for the Hungry $193 million $183 million

Doctors Without Borders, USA $202 million $181 million

Annual expenditures include program, administrative, and fundraising expenses.

Source: Data from Charity directory. Glen Rock, NJ: Charity Navigator; 2012.

12.3 Paying for Global Public Health 293

Table 12~3 Major multipurpose human services and disease-specific charities based in the United States.

Name

American Red Cross

Feeding America

Volunteers of America

American Cancer Society

American Heart Association

Susan G. Komen for the Cure

The Leukemia & Lymphoma Society

American Kidney Fund

National Cancer Coalition

Alzheimer's Association

Juvenile Diabetes Research Foundation International

March of Dimes

Muscular Dystrophy Association

American Diabetes Association

Elizabeth Glaser Pediatric AIDS Foundation

Cystic Fibrosis Foundation

Annual Expenditures Program Expenditures (2010-2011) (2010-2011)

$3422 million $3157 million

$1180 million $1185 million

$929 million $831 million

$948 million $679 million

$598 million $468 million

$343 million $283 million

$281 million $215 million

$224 million $219 million

$181 million $175 million

$225 million $169 million

$204 million $168 million

$206 million $155 million

$178 million $139 million

$190 million $137 million

$144 million $128 million

$134 million $109 million

Annual expenditures include program, administrative, and fundraising expenses.

Source: Data from Charity directory. Glen Rock, NJ: Charity Navigator; 2012.

294 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

12.4 TYPES OF GLOBAL HEALTH PROGRAMS

A variety of different activities can fall under the umbrella of global health services and programs. Many global health organizations and agencies work in several of these areas, while some specialize in just one domain. These areas include:

• Research and education activities that seek to understand global health concerns, identify effective solutions, and disseminate critical infor- mation to targeted audiences such as patients and families, healthcare providers, community health workers, public health professionals, policymakers, affected communities, or the general public. This is the focus of many disease-specific charities like the American Cancer Society and the American Heart Association.

• Clinical services provided by hospitals, clinics, health centers, and other direct patient care providers.

• Relief aid that meets the immediate needs of people who might other- wise not have access to water, food, shelter, emergency medical care, and other urgent necessities. Relief services are often required after major natural disasters and during wars.

• Community development programs that work with local com- munities to improve living conditions. One type of development program focuses on microcredit, very small loans (microloans) to novice entrepreneurs who are unable to get a loan through a conven- tional bank because they do not have collateral, steady employment, or a credit history, or because they are women. The interest rates are typically much lower than those offered by conventional banks, and most microcredit programs also provide some form of financial education and community support. The Grameen Foundation and other organizations help establish and support microfinance institu- tions. Other community development organizations may specialize in health, education, agriculture, water and sanitation, or other sectors.

• Advocacy initiatives that aim to increase awareness of a specific cause and to influence policy and resource allocation decisions related to that cause. For example, Amnesty International and Human Rights Watch work to bring global attention to human rights violations.

• Logistics efforts that deliver food, medications, medical equip- ment and supplies, and other goods and services to people and

12.5 Implementing Health Programs 295

communities in need. Many of the global partnerships that are work- ing to increase vaccination coverage for children in low-income countries or to expand access to affordable medication for HIVI AIDS have expertise in the entire logistics pathway from procure- ment, production, and packaging to transportation, storage, and distribution.

The diversity of payers and players in global health highlight the wide variety of career paths that can lead to work in the global health arena.

12.5 HEA.LTH

Thousands of governmental, corporate, and nonprofit groups imple- ment the various research and education, clinical, relief, development, advocacy, and logistics projects and programs that facilitate global health.41,42 usually have clear goals and defined end dates.

are usually ongoing groups of related projects.) The agen- cies and organizations that manage these functions-the ones that spend global health money-are not necessarily the same ones that provide the funds for these activities. 32 Some groups specialize in fundraising; others in implementation.

The majority of clinical health services and health education programs are implemented by, or with the approval and assistance of, national min- istries of health and their state or provincial and district health offices. Major relief and development efforts are also usually conducted with the approval of the national government. Supplies, technical assistance, and management oversight may be provided by UN agencies (such as the WHO, UNICEF, and other specialized programs), foreign governments (through their international development or international cooperation agencies), public-private partnerships, nongovernmental organizations, universities and colleges, businesses, and individual professionals and volunteers. Although sometimes the coordination between various groups is poor, resulting in duplication of efforts in one area, the goal is for the various players to work together to promote health, often by letting each contributor focus on its own area of expertise, whether that is water and sanitation or childhood vaccination or agricultural development or something else. The various participants in global health initiatives tend to take on different roles that are consistent with their goals or mandates and are in line with their particular capabilities.

296 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

12.S.A National and Local Governments

National governments provide the bulk of health services and payment for health systems. They decide, at least in part, who gets to use the health- care system, the choice (if any) that people have about where to seek care, the kinds of services that are covered by social security or health insurance, the level of training required for healthcare practitioners, and the types of facilities available. Even when the healthcare system is not nationalized, the government can still dictate, for example, what services must be covered by insurance and what educational and testing requirements must be fulfilled before people are licensed as doctors, nurses, dentists, and therapists.

The national government is also responsible for the public health system. It can set guidelines for nutrition, vaccination schedules, screening, and other preventive measures, and it can regulate the production and sale of health supplies, medications, and food products. It can also form public health partnerships with other nations and agencies that allow it to share information and quickly respond to infectious disease threats that require an international response. And it can negotiate with companies, for example, to secure cheaper prices on medications.

Another function of national governments is sponsoring health research. In the United States, the National Institutes of Health (NIH) is the federal focal point for medical research. The NIH is divided into more than 20 separate institutes, and research funded by nearly any of the divisions can be conducted internationally, provided that the research protocol meets rigorous standards for ethical human subjects research. The U.S. Centers for Disease Control and Prevention (CDC) is also involved in health research, and it plays a unique role in responding to international public health crises. The CDC responds to international health emergencies, including outbreaks, when invited to do so by the country or countries affected, and works with researchers in other nations to conduct field research, to set up monitoring and surveillance systems, and to train public health workers.43

The United Kingdom's Medical Research Council (MRC), the Canadian Institutes of Health Research (CIHR), Brazil's Fundac;ao Oswaldo Cruz (Fiocruz), the Indian Council of Medical Research (ICMR), and the Kenya Medical Research Institute (KEMRI) are other examples of nationally sponsored health research agencies.

Additionally, governments have the ability to shape public policies in ways that enhance health and reduce health disparities. The "Health in All Policies" approach recognizes that health is dependent on other critical public sectors-including agriculture, urban development, energy,

12.5 Implementing Health Programs 297

1Z~9 Framework for health in all policies.

commerce, education, and transportation, among others 12-9)- and that, conversely, a healthy population makes it possible for those other sectors to thrive. 44

For international health initiatives, national and local governments can serve as a point of interface between local populations and international visitors. The implementation of a sponsored public health program is usu- any smoother and more successful when national or local government officials and local leaders have endorsed the plan. 45 For example, if a voluntary organization from the United States wants to distribute free insecticide-treated bednets (ITNs) in rural communities in Sierra Leone, the standard protocol is for the leaders of the organization to meet with local government, community organization, andlor religious leaders to ask for their support. If the project is deemed to be a locally beneficial one, the local leaders and other community representatives will be able to help the visiting group to set up a locally appropriate distribution system and to spread the word about the free ITNs to the community. The local leaders will also be able to tell the visitors if they do not need or want ITN s, if the visitors are scheduled to come at a bad time (say, during harvest time or on a day when there is a funeral or other special event), or if the presence of the visitors (who might need meals and a place to sleep) will place an undue burden on the community. Organizations that want to work on a bigger scale might need to get the approval of the national Ministry of Health and other national governmental offices. This is true for nearly intervention

298 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

programs, and essential for any projects that involve testing a new medical product (When a new medication or other health product is being tested, the sponsoring organization must obtain approval from the ethics review committee of the Ministry of Health, or another approved authority, before starting the experimental trial.)

The UN was founded in 1945 by 51 member states, and by 2011 had expanded to 193 member nations. The goals of the UN are "to maintain international peace and security," "to develop friendly relations among nations," and "to achieve international co-operation in solving international problems of an economic, social, cultural, or humanitarian character.,,46 The General Assembly, which is composed of one voting representative from each member state, is the main policy-setting group for the UN. The I5-member Security Council is responsible for peace-building, mediation, and security operations, and the International Court of Justice provides legal judgments and advisory opinions. The specialized functions of the UN are carried out its agencies, offices, funds, programs, and subsidiary bodies, each of which has a unique mandate

The WHO is the primary health agency of the UN. 47 ,48 The WHO is governed by the World Health Assembly, composed of one representa- tive from each UN member state, which convenes every May to approve a budget, make policy decisions, and approve conventions, agreements, and regulations. The first global health treaty negotiated by the WHO is the Framework Convention on Tobacco Control (FCTC), which details specific measures, such as increased taxation and comprehensive bans on advertising of tobacco products, that should be taken to reduce the demand for tobacco and the supply of tobacco.49 More broadly, the WHO conducts research on health issues of international importance, monitors disease epidemics, col- lects health statistics, develops standards of practice (such as child growth charts and recommendations for laboratory and diagnostic procedures), and creates educational materials. The WHO also provides assistance to national governments that ask for technical assistance, and coordinates the health work of other UN agencies. For example, the WHO coordinated the small- pox eradication campaign in the 1960s and 1970s and is now coordinating the global polio eradication campaign.

Other UN agencies are also working on the ground in member states on health-related activities. For example, each year UNICEF provides

12.5 Implementing Health Programs 299

Table 12-4 Examples of the primary functions of United Nations agencies.

Agency, Program, Fund, or Office Primary Work Area

United Nations Children's Fund (UNICEF) Children

United Nations Environment Programme (UNEP) Environmental health

World Health Organization (WHO) Health

United Nations Programme on HIV/AIDS HIV/AIDS (UNAIDS)

United Nations Office of the High Commissioner Human Rights for Human Rights (OHCHR)

World Food Program (WFP) Hunger

International Court of Justice Justice

International Labour Organization (ILO) Labor

United Nations Development Programme (UNDP) National development

United Nations Population Fund (UNFPA) Population and reproductive health issues

United Nations High Commissioner for Refugees Refugees (UNHCR)

Food and Agriculture Organization (FAO) Rural development

United Nations Human Settlements Programme Urban development (UN-HABITAT)

humanitarian aid in nearly 100 countries, providing essential medications to children, treating malnutrition, supporting community water projects, distributing health kits to refugees, donating teaching materials to rural schools, assisting victims of violence, and engaging in other emergency care,50 and each year the World Food Programme delivers emergency food aid to about 100 million people. 51

National governments are often involved in sponsoring relief and development work internationally and cooperatively. For example, most developed countries have a governmental division dedicated to working with developing countries, and many of these agencies have a visible

300 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

Table 12~5 Examples of international development and cooperation agencies.

Country Abbreviation Agency

Australia AusAID Australian Agency for International Development

Belgiurn DGDC Belgian Development Cooperation

Canada CIDA Canadian International Development Agency

Denmark Danida Danish development cooperation

Finland FINNIDA Finnish International Development Cooperation

France AFD Agence Fran<;:aise de Developpement

Germany GTZ Deutsche Gesellschaft fUr Internationale Zusammenarbeit

Japan JICA Japanese International Cooperation Agency

Norway Norad Norwegian Agency for Development Cooperation

Spain AECID Agencia Espanola de Cooperacion Internacional para el Desarrollo

Sweden SIDA Swedish International Development Cooperation Agency

United Kingdom DFID U.K. Department for International Development

United States USAID U.S. Agency for International Development

presence on the ground in low-income countries While each of these agencies works to alleviate poverty and improve health, the goals, methods, and targeted recipient countries vary based on the political situa- tions and historic connections of the donor nation. For example, the United Kingdom's Department for International Development (DFID) tends to work especially closely with member nations of the British Commonwealth, which are almost exclusively former British colonies or protectorates,52 and the Japan International Cooperation Agency (nCA) works worldwide but is especially active in Asian countries with which it has economic ties. 53

Foreign aid from the United States is administered by the U.S. Agency for International Development (USAID) and other entities within the U.S. Department of State, including the Peace Corps, and also by the U.S. Department of Defense (DOD), the U.S. Department of the Treasury (which

12.5 Implementing Health Programs 301

Table 12~6 U.S. Global Health Initiative principles.

Increase impact through strategic coordination and integration

Encourage country ownership and invest in country-led plans

Build sustainability through health systems strengthening

Strengthen and leverage key multilateral organizations, global health partner- ships, and private sector engagement

Focus on women, girls, and gender equality

Improve metrics, monitoring, and evaluation

Promote research and innovation

Source: Information from The United States Government Global Health Initiative strategy. Washington DC: U.S. GHI; 2009.

manages all multilateral aid contributions), the Millennium Challenge Corporation (MCC), and other agencies.22 Many ofthese efforts are coordi- nated by the U.S. Global Health Initiative (GHI), which has identified guid- ing principles for all of the country's global health programs 54

The five core operational goals of USAID are: (1) supporting trans- formational development, especially in the areas of governance, human services, and economic growth; (2) strengthening fragile states; (3) sup- porting U.S. geostrategic interests, particularly in countries such as Iraq, Afghanistan, Pakistan, and Israel; (4) addressing transnational problems, including HIV / AIDS and other infectious diseases, climate change, and the illegal drug trade; and (5) providing humanitarian relief. 55 These goals are achieved through work in the areas of democracy, conflict prevention, and humanitarian assistance; economic growth, agriculture, and trade; and global health. 55 USAID also helps implement special presidential initia- tives, such as the President's Emergency Plan for AIDS Relief (PEPF AR) and the President's Malaria Initiative (PMI), and oversees the U.S. contri- butions to global health partnerships.

Dozens of nonprofit public-private partnerships are currently working to set and accomplish goals for selected global health issues The goals of these various global health partnerships include developing new products (such as new medicines, vaccines, and diagnostic tools),

302 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

12-7 Examples of global public-private health partnerships.

Foundation for Innovative New Diagnostics (FIND)

Global Alliance for Improved Nutrition (GAIN)

Global Alliance for Vaccines and Immunisations (GAVI)

Global Fund to Fight AIDS, Malaria, and Tuberculosis (GFATM)

Health Metrics Network (HMN)

International AIDS Vaccine Initiative (IAVI)

Medicines for Malaria Venture (MMV)

Roll Back Malaria (RBM)

Stop TB Partnership (Stop TB)

UNITAID

distributing donated or subsidized health products, strengthening health services and health informatics systems, educating the public about par- ticular health issues, improving the quality or regulation of products, and coordinating complex global health efforts. 56

When these partnerships are successful, all of the involved parties ben- efit. The corporate sector and other private entities see a return on their investment because the collaboration pays for research and development activities, the distribution of a subsidized health product may open up new markets to donor companies, and nonprofit work boosts participating companies' public profiles. The public sector and governmental agencies attain an effective mechanism for achieving the scientific, foreign relations, and humanitarian goals of the donor countries. And global public health is advanced when these partnerships increase the visibility of specific health issues, raise funds to address these issues, stimulate research and develop- ment, establish international treatment protocols and technical standards, and improve access to health care. 57

sometime called '1101- are nonprofit organizations that are privately

managed and receive at least some their funding from private sources. NGOs may focus on one particular issue, like cultural awareness or environ- mental preservation, or may address multiple issues in a particular town or region or country. NOOs may be involved in direct action like distributing

12.5 Implementing Health Programs 303

food aid or may focus entirely on lobbying and advocacy. Some NGOs are sponsored by religious or religiously

affiliated organizations, and although they rarely require that aid recipients adhere to a particular faith or listen to an evangelistic message, they are representing a particular religious tradition. Examples of PBOs include the American Jewish World Service, Catholic Relief Services, Church World Service, Islamic Relief, and World Vision. Many NGO§

are involved in a spectrum of relief aid, development work, advo- cacy, and logistics; some also engage in clinical care and research.

Most large global health NGOs raise funds from individuals, private foundations, and governmental sources. One challenge for many NGOs is balancing the goals of donors and the desires of recipients. Directed dona- tions occur when a donor gives money and stipulates that it must go to a particular cause. Sometimes this works well, but other times donors may not be aware of conditions in the recipient community. A community that wants to upgrade its local health clinic by adding a solar panel to provide electricity to the building may instead receive a microscope that they can- not use without electricity. A school may receive a donation of textbooks written in a language not spoken by any of the students. Or a donor may send old medical equipment that cannot be maintained by the community or a water pump that cannot be locally repaired. A related concern is that not all "nongovernmental" organizations are completely independent from gov- ernments, as several of the largest U.S.-based international NGOs receive a large portion of their budgets from the U.S. government. These NGOs must sometimes navigate complex political terrains.

Another challenge for NGOs operating internationally is deciding which aspects of budgeting and operations should be handled by recipient coun- try staff and which should be managed by representatives of the donors. Some INGOs hire primarily local workers from the recipient country while others prefer to hire expatriates to be managers, accountants, and field staff.

or "expats," are people working in a foreign country for their home government, a business, the press corps, an NGO, or another organiza- tion, and who intend to move back to their home countries when their job is completed.) INGOs must also decide how closely they will work with officials from host countries and how to address potential problems with corruption and mismanagement. Some humanitarian groups feel that it is important to remain publicly neutral about political matters, and others feel compelled to speak openly about any injustices they witness. Cross-cultural communica- tion skills are a necessity for all people working for an INGO, because they must be able to relate to both the funding agency and the host community.

304 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

NGOs also have to consider the social and political impact of their actions. The goal of most NGOs is to improve the well-being of individuals and communities, but well-intentioned efforts can sometimes have harm- ful side effects. The presence of a relief NGO may exacerbate conflicts by providing supplies that allow violence and instability to continue or by encouraging displaced persons to congregate in one area that could be targeted for attack. The long-term presence of a community development NGO may promote a "culture of dependency" and prevent the development of government or commercial service providers.

However, NGOs that successfully navigate these complex situations playa very important role in global health. Because most NGOs are not political, they can reach populations that might otherwise be underserved. Because NGOs often work for decades in the same communities, they build relationships and trust that allow for quick responses to emergen- cies, and their long-term commitments result in sustainable development NGOs can also serve as points of connection between communities and international payers and players, using their networks to help new projects and programs quickly reach their target audiences. For example, Rotary International members all over the world have worked together on the polio eradication campaign, with local Rotary clubs in endemic areas facilitating vaccination campaigns in their communities. 58 Thus, NGOs are often the organizations that actually deliver aid to the people who need it most.

The International Committee of the Red Cross (ICRC) works with national Red Cross and Red Crescent Societies and the International Federation of Red Cross and Red Crescent Societies to provide humani- tarian aid to people in areas affected by war and other armed conflicts. The ICRC is unique among private organizations because it is an independent organization guided by its own set of rules and principles (humanity, impar- tiality, neutrality, independence, voluntary service, unity, and universality) but it is officially sanctioned the Geneva Convention and international law to provide specific humanitarian services. 59 ICRC is funded through governmental support, contributions from national Red Cross and Red Crescent societies, and private donations.

The JCRC aids both civilian and military victims of conflicts by visiting prisoners of war, searching for missing persons, transmitting messages

12.6 Discussion Questions 305

between separated family members, reunifying dispersed families, monitor- ing compliance with the international laws that pertain to armed conflict, and providing basic services to civilians such as food, water, and medical assistance.

N adonal Red Cross and Red Crescent societies are autonomous from the ICRC, and provide a variety of services that meet needs in their com- munities. Examples of local Red Cross activities include maintaining blood banks, providing first aid training, and offering assistance to those who have been affected by natural disasters.

A growing number of businesses are contractors that receive government and foundation funds to implement global health projects. For example, Chemonics International Inc., John Snow Inc., Abt Associates Inc., and Family Health International (FHI) are among the companies that received more than $100 million in 2011 to run international programs on behalf ofUSAID. 6o

Transnational corporations and other businesses not specializing in inter- national development can also contribute to international health efforts by donating money and products and by helping their own workforce to be healthy-creating healthy work environments, ensuring that safety protocols are followed, covering the health expenses of workers and their families, and educating workers about health, nutrition, and injury preven- tion. Thus, nearly all workers have roles to play in furthering their own health, the health of their families and communities, and the health of the global public at large.

nJs DISCUSSION QUESTIONS

1. How much do you spend out-of-pocket on health care and health-related expenses each year? What proportion of your income do you spend on health? Does this seem like a reasonable amount?

2. Do you have health insurance? If so, how much does it cost? Does it adequately cover your needs?

3. How much are you willing to pay out-of-pocket each month to have health insurance? What services would you expect to receive for that payment?

306 CHAPTER 12 GLOBAL HEALTH PAYERS AND PLAYERS

4. Have you ever made a decision not to see a doctor when sick or injured, not to fill a prescription, not to have a test your doctor recommended, or otherwise not received medical care because you were worried about your ability to pay for it? How did that make you feel?

5. Would you prefer to live in a country with a public (tax-funded) healthcare system or in a country with a privately funded healthcare system? Why?

6. Do you think your country spends too much, too little, or the right amount on international assistance?

7. If you had $100 to donate to an organization involved in global health, which one would you give to? Why?

8. If you were going to spend one month in a low-income country doing global health volunteerism, which organization would you choose to work with? Why?

9. If you were going to found a global health NGO, what specific area would you want the NGO to focus on?

10. How does your intended career path overlap with the work of global health?

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in Transition. Copenhagen: WHO European Observatory on Health Systems and Policies; 2011.

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20. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray ClL. Public financing of health in developing countries: a cross-national systematic analysis. Lancet. 2010;375: 1375-1387.

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and where it goes. Health Policy Plan. 2009;24:407-417. 33. Global partnerships: humanitarian programs of the pharmaceutical industry in

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Health. 2004;9(4 suppl):AI-A3. 35. The end in sight: 2020 INSight. Decatur GA: International Coalition for Trachoma

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37. Global impact report 2011. Washington DC: American Red Cross; 2011. 38. Giving USA 2012: The annual report on philanthropy for the year 2011. Executive

summary. Chicago: The Giving Institute; 2012. 39. Charity directory. Glen Rock, NJ: Charity Navigator; 2012. 40. Charity trends. Kent, UK: Charities Aid Foundation (CAF); 2012. 41. Gostin LO. A Framework Convention on Global Health: health for all, justice for all.

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1301 GLOBALIZATION AND GLOBAL HEALTH

One of the key components of global health as a field new and distinct from international health is its focus on issues common to all countries in the world. Globalization is making many of these concerns more promi- nent, including urbanization and health, emerging infectious diseases, food safety, security, and the health impacts of global environmental change.

Gnobalization has many definitions, most of which are very specific to a particular discipline. For example, economists use globalization to refer to the expansion and integration of economic activity and policies between nations. 1 Globalization is seen in the increasing number of global govern- mental and nongovernmental organizations, the proliferation of multilateral trade agreements, increases in foreign direct investment, the rise of global supply chains, increased population mobility (including tourism, urban migration, and forced displacements), and increased cultural diffusion. The globalization of the world economy is very evident the items people use on a daily basis. For example, many of the telecommunications devices, clothes, appliances, and other consumer goods purchased in the United States are imported from other countries. 2

Globalization is not new to the field of public health. Infectious diseases like plague and smallpox spread across Europe and Asia more than a thousand years ago when sea and land trade routes, like the Silk Road, linked China, India, and the Mediterranean. The infectious diseases carried by the Europeans who explored the Americas in the 15th century caused the decimation of many indigenous American popUlations, and some infections indigenous to the Western hemisphere (such as syphilis) made their way back to Europe and

309

310 CHAPTER 13 GLOBALIZATION AND HEALTH

sparked mass epidemics.3 Early European explorers to the New World also brought tobacco from the Americas to Europe, increasing the prevalence of chronic diseases. (And, more recently, as tobacco use declines in the United States and some other high-income world regions, tobacco marketing and sales in Asia, Latin America, Africa, and Eastern Europe are increasing.4)

Infectious diseases have never stopped at national boundaries, and modem transportation allows for a new infectious disease that emerges in any part of the world to be transported by aircraft to any other part of the world within hours rather than weeks or months. The original cases of SARS (severe acute respiratory syndrome) occurred in Guangdong, in southern China, in November 2002; in March 2003, SARS spread to Hong Kong and then, days later, a secondary outbreak occurred in Toronto, Canada, with additional cases in more than two dozen countries. 5 If a strain of highly pathogenic avian influenza develops the ability to spread easily from human to human, an even faster and more widespread dissemination of the infection across the globe is expected. 6 Globalization means that humans are tied together, and a problem in one part of the world can quickly become a global issue.7

New concerns about globalization and health move beyond infectious disease outbreaks (which remain a worry) to encompass drug resistance, noncommunicable diseases (NCDs), nutrition, the safety of imported goods (including, for example, toys coated in lead paint as well as foods with microbial or chemical contaminants), peace and conflict, bioterrorism, global climate change, and a host of other issues.

13.2 URBANIZATION AND HEALTH

On average, urban residents have greater access than rural residents to water and sanitation, to a relatively reliable public transportation system, and to healthcare providers and health technologies. Electricity in cities reduces cooking time and makes it easier to store food safely. Communications systems, such as radio and television, broadcast news and entertainment shows as well as emergency warnings and health messages. Urban women have more opportunities to pursue additional education and to find employ- ment outside the home. Pregnancy in cities is safer because of greater access to antenatal care and assistance by medical professionals during delivery.

However, the benefits of urbanicity are not available to all urban resi- dents. 8,9 Table 13-1 compares rural, unplanned urban, and planned urban communities. Many people who move to cities end up living in unplanned settlements (sometimes called shantytowns, slums, or squatter camps) where

13.2 Urbanization and Health 311

Table 13-1 Comparison of health risks associated with rural living, unplanned urban living, and planned urban living.

Sector Rural Unplanned Urban Planned Urban

Water .. May have minimal ., May have minimal .. Reliable access access to improved access to afford- to safe, clean water sources able clean water drinking water

.. Risk of microbial @ Risk of microbial contamination and industrial/

agricultural chemical contamination

Sanitation '" May have " May have " Sewage system inadequate inadequate sanitation facilities sanitation facilities

.. Open defecation in '" Open defecation in a field away from the street may be the house may be common common

Trash '" Solid waste is " No collection of .. Solid waste is disposal burned or buried solid waste collected and

iii Trash heaps create removed

a habitat for insect and rodent vectors

Fuel .. Solid fuels, which @ Solid fuels, which " Electricity may be able to be may be expensive collected locally

Nutrition " May have limited " May have limited .. Adequate access ability to purchase access to afford- to healthy and safe food able, healthy foods dietary choices

... Can usually grow, .. May not have gather, or hunt for space for a garden food

Health " Facilities may be ., Facilities may " Basic, emergency, facilities far from home and be crowded and and specialty

may provide only understaffed healthcare (includ- basic care ing mental health

and rehabilitation) facilities are available

(Continues)

312 CHAPTER 13 GLOBALIZATION AND HEALTH

Table 13-1 (Continued)

Sector Rural Unplanned Urban Planned Urban

Air quality • Indoor air pollution • Both indoor • Some outdoor air from burning and outdoor air pollution biomass pollution • Some indoor air

• Noise pollution pollution from building materials

Chemical • Potential exposure • Potential exposure • Little exposure Hazards to agrochemicals to industrial to industrial

like fertilizer and waste or agricultural pesticides hazards

the quality of life is generally worse than rural life. Poorly constructed homes, often made from cardboard, scraps of metal and wood, or other found items, provide little comfort or privacy. Residents may not have access to toilets, and trash and human waste may collect near the home and attract rodents and insects. Living in close proximity to large numbers of people and their animals increases the risk of insect borne and animal borne diseases. Violence and road-traffic accidents (often of the motor vehicle versus pedestrian variety) may be common. Urban workers may face new occupational hazards, and may not have access to affordable emergency healthcare services. It may be difficult to grow or to purchase nutritious foods, and there may be little time or space for exercising. Unplanned com- munities in urbanizing cities often form in undesirable locations near noisy and polluted highways or industrial centers that exacerbate asthma and cardiovascular conditions. Informal dwellings are often built in floodplains or on other vulnerable lands, and lack of drainage systems means that floods carry feces and other waste into homes.

Each day, thousands of people move from rural areas to cities in search of better jobs, higher incomes, more social opportunities, and greater conveniences. This process of urbanization affects both urban and rural residents. Rural women, for example, may bear a particularly heavy burden when their husbands move to cities to find wage employment, leaving the women with the responsibility of completing all of the household chores. Or parents who move to the city may have to leave their children in the care of grandparents, which puts a strain on three generations.

Although urbanization is occurring in nearly every part of the world (Figures 13-1 and 13-2),10,11 the rates are particularly high in developing countries, which are now home to many of the world's largest metropolitan

· ...

D Missing data • <40%

40-59.9%

.60-79.9%

• 2::80%

Figure 13-1 Percent of each country's population that lives in an urban area in 2010. Source: Data from World health statistics 2011. Geneva: WHO; 2011.

~\---- ,~' 4'

'"- ~ N

t § . ..... <5' ;:s ~ ;:s ~

~ ~

§:

W >-' W

314 CHAPTER 13 GLOBALIZATION AND HEALTH

areas (Table 13--2).12 Figure 13--3 highlights the trend in low-income countries toward rapid urbanization. In these areas, the birth rates remain high in both rural and urban areas, but rural-to-urban migration causes cities to grow at an especially rapid rate. In many high- and middle-income regions, birth rates are low and rural-to-urban migration is causing rural populations to shrink.12

100.------------------------------------------------.

o USA South Poland Brazil China India Kenya Sierra

Korea Leone

Figure 13-2 Proportion of the population living in an urban area.

Source: Data from Human development report 2010. New York: UNDP; 2010.

5,----------------------------------------, 4+---------------------------------- 3+----------------------- 2+------------------------

o -1+---

-2+---------------------- -3~--------------------------------------~

USA South Poland Brazil China India Kenya Sierra Korea Leone

• Rural annual growth rate

III Urban annual growth rate

Figure 13-3 Rural and urban population growth rates between 2005 and 2010.

Source: Data from World urbanization prospects, the 2011 revision. New York: Department of Economic and Social Affairs, United Nations; 2012.

13.2 Urbanization and Health 315

TZlb!e i3-~2 The world's megacities (urban areas of 10 million or more inhabitants) in 2011. Cities in low- and middle-income countries are shaded in grey.

Rank Metropolitan Area Population

Tokyo, Japan 37.2 million

4 New York City, USA 20.4 million

13 Los Angeles, USA i 3.4 million

17 Osaka, Japan 11.5 million

23 Paris, France 10.6 million

Source: Data from World urbanization prospects, the 2011 revision. New York: Department of Economic and Social Affairs, United Nations; 2012.

316 CHAPTER 13 GLOBALIZATION AND HEALTH

13.3 EMERGING INFECTIOUS DISEASES

Even as modern science has allowed the control and even eradication of some diseases, other diseases previously not found in humans are appearing. Emerging infectious diseases (EIDs) occur when a new pathogen begins to affect human populations or an existing pathogen changes the kind of disease it causes. The agent might evolve in a way that makes it easier to transmit to a susceptible person (increased transmissibility) and, therefore, more common (increased incidence). It might change so that it causes a new set of symptoms or more severe symptoms (increased virulence). In some cases, an infectious agent that usually affects only nonhuman hosts may adapt in a way that makes it infectious to humans. Sometimes an infec- tious agent may change in a way that allows for a different portal of entry, perhaps developing the ability to spread through airborne transmission. Other infections, called reemerging infections, were controlled at some point in the past but are becoming problematic again. 13- 15 Consider just a few of the many EIDs identified in recent decades:

• Within months of methicillin being released for use as an antibi- otic in 1960, cases of methicillin-resistant Staphylococcus aureus (MRSA) were reported. 16 MRS A is very difficult to treat, and it can cause severe "flesh-eating" infections (necrotizing fasciitis) and bloodstream infections. MRSA is now common in hospitals (where it is called hospital-acquired or HA-MRSA), but the infection can also be transmitted by unsterilized sports equipment and other everyday items that cause community-acquired or CA-MRSA. Drug-resistant strains of bacteria are often hardier than drug-sensitive strains, so inappropriate access to drugs in one nation (such as infected persons taking an inappropriate type of antibiotic or too few doses of an appropriate one) can rapidly cause a global antimicrobial resistance problem. 17

• Legionnaires' disease is a severe type of pneumonia that was first identified in 1976 following a conference of the American Legion in Philadelphia. 18 (The mild form is called Pontiac fever.) The bacteria that cause Legionnaires' disease live in water. When modern water distribution systems like air cooling units, spas, and humidifiers aerosolize the bacteria, they can be inhaled and lung infections can occur. 19

• An outbreak of Ebola virus, a tropical hemorrhagic fever, was first reported in 1976.20 Outbreaks are rare, but still occur in central Africa,

13.3 Emerging Infectious Diseases 317

and the case fatality rate is high. 21 The reservoir for the infection remains unconfirmed, even though international research teams have been searching for years for proof of an animal host.22

e Although hantaviruses have caused human disease in many parts of the world for a long time, hantavirus pulmonary syndrome (HPS) was first seen in 1993 in the isolated Four Comers region of the southwest United States. Several young adults developed severe pneumonia after they inhaled aerosolized rat urine or feces while doing a spring cleaning of rural summer homes.23 HPS outbreaks have since been reported in Central America and South America. 24

@ The first cases of acquired immunodeficiency syndrome (AIDS) were diagnosed in 1981 in the United States. 25 The human immunodefi- ciency virus (HlV) was not identified until several years later. 26 By the mid-1990s, cases had been reported from nearly every country in the world, and more than 5 million people had died of AIDS. 27

" Cholera, a waterborne bacterial infection that can travel in ocean waters from one nation's shores to another, appeared in South America for the first time in nearly 100 years in 1991. It was first identified in Peru but quickly spread to Ecuador and Colombia, and in less than a year it had spread throughout South America and Central America, including to Mexico and several Caribbean countries. 28 ,29

e Although cases have occurred in Egypt, Sudan, and Uganda for decades, an outbreak of encephalitis due to West Nile Virus happened in the United States for the first time in 1999?O The virus cycles between mosquitos and vertebrates (usually birds, but sometimes humans or other animals). A small proportion of infected humans develop severe nervous system complications?1 Just a few years after the first cases were identified in New York, cases had been reported from nearly all of the contiguous states. 32

The U.S. Institute of Medicine reports that these new health threats derive from a complex interaction of genetic and biological factors; physical environmental factors; ecological factors; and social, political, and economic factors (Table 33 As the world population increases (#6), humans and domestic animals move into previously uninhabited natural environments (#5) and are exposed to new plants, animals, and microbes. Alteration of the environment (#4), such as deforestation, dam building, and manipulation of wetlands, creates new environmental reservoirs for infectious agents and their hosts, and natural disasters (#3) like floods

318 CHAPTER 13 GLOBALIZATION AND HEALTH

Table 13-3 Risk factors for emerging infections.

Microbial adaptation and change

2 Human susceptibility to infection

3 Climate and weather

4 Changing ecosystems

5 Economic development and land use

6 Human demographics and behavior

7 Technology and industry

8 International travel and commerce

9 Breakdown of public health measures

10 Poverty and social inequality

11 War and famine

12 Lack of political will

13 Intent to harm

Source: Information from Smolinski, MS, Hamburg MA, Lederberg J, editors. Committee on Emerging Microbial Threats to Health in the 21 st Century. Institute of Medicine. Microbial threats to health: emergence, detection, and response. Washington DC: The National Academics Press; 2003.

and droughts can alter the landscape and introduce new infectious agents to a region. Changes in dietary and other behaviors (#6) that become trendy and spread globally may also facilitate transmission. Urbanization facili- tates emergence as people with different strains of infections interact with one another (#2) and create new habitats for vectors (#5). Technology is also speeding up the rate of emergence. Modem transportation (#8) has made it possible for an infectious person to travel nearly anywhere in the world within hours. Healthcare innovations (#7) have created new risks and risk groups. Advanced medical therapies like the immunosuppressive drugs used by people who have had organ transplants and the technol- ogy for keeping premature infants alive have created new populations of highly susceptible people (#2). Nosocomial infections (also called hospital-acquired infections, or HAIs) may be very hardy and difficult to treat, and antimicrobial resistance is increasing (#1). Other technological advances have created new places for infectious agents to grow and new methods of dispersion. New infectious diseases can emerge anywhere in the world and spread quickly, so the distinction between local public health problems and global ones is increasingly limited.

13.4 Nutrition and Food Safety 319

NUTRITION AND FUOD

Nutrition globalization is seen in changing eating habits, the increas- ing variety of foods on grocery store shelves, the growing number of international restaurant chains, and the global marketing of food products. International food markets have grown significantly in recent decades. For example, the proportion of food consumed in the United States that is imported increased from 12% in 1990 to 14% in 2000 to 17% in 2009

34 This cross-border trade in foods has created a new set of concerns about food safety.

A wide variety of foods have been implicated in outbreaks, including fruits and vegetables, meats and poultry, eggs, seafood, dairy products, bakery items, and unpasteurized fruit juices?5 The causative agents in foodborne outbreaks include a diversity of bacteria (Campylobacter, E. coli, Listeria, Salmonella, Shigella, and others), parasites (such as Cryptosporidium, Giardia, and Toxoplasma gondii), and viruses (including noroviruses, rotaviruses, astroviruses, and hepatitis A virus, among others).36 In addition to microbial contamination, chemical contaminants are increasing threats to health. Concerns have been raised

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320 CHAPTER 13 GLOBALIZATION AND HEALTH

about heavy metal poisoning from mercury in fish, pesticide residues, chemical additives and preservatives, and other issues. 37 (These complex considerations have contributed to the development of the One Health con- cept that promotes the integration of human, animal, and environmental health initiatives. 38)

While most outbreaks are caused by locally grown and processed foods,39 an increasing number of large multinational foodborne outbreaks are being reported.4o The Codex Alimentarius International Food Standards, which are compiled by scientific panels hosted by the United Nations, pro- vide guidelines about food safety, but these are not binding on countries or food producers, and they can be difficult to enforce.41 Additionally, labeling requirements are not standardized across markets, and countries have different expectations about the use of additives and preservatives, fortification and enrichment with vitamins and minerals, and the use and labeling of genetically modified organisms (GMOs). As the food industry becomes increasingly global, it may become more difficult for governments and consumers to have confidence that their food supply is safe. However, several simple food safety practices can help protect consumers at home (Table 13-4).42

Globalization is also having an impact on social and cultural eating behaviors, breastfeeding practices and attitudes, and perceptions of physical beauty. Some anthropologists have used the terms New World Syndrome, "Coca-colonization," and "McDonaldization" to refer to the diseases of affluence (such as obesity, diabetes, heart disease, and hypertension) that occur after a population replaces its traditional diet with processed foods. 43 ,44 Dietary changes may include increased portion sizes, more snacking, more meals eaten outside the home, replacing water with sweetened beverages,

Table 13-4 Key food safety practices.

Clean

Separate

Cook

Chill

Wash hands and surfaces often

Avoid cross-contamination between uncooked and ready-to-eat foods

Cook meats, eggs, and dairy products to a proper temperature

Refrigerate foods promptly to keep them at a safe temperature

Source: Information from Medeiros LC, Hillers VN, Kendall PA, Mason A. Food safety education: what should we be teaching to consumers? J Nutr Educ. 2001; 33:108-113.

1304 Nutrition and Food Safety 321

eating more animal protein, cooking with more oil, adding more sweeteners to the diet, and shifting from consuming whole grains to refined grains.45

This nutrition transition can result from a variety of globalization processes, including urbanization, new technologies, global media, and international transportation and trade.

A related change includes adaptations in cultural perceptions of beauty. When the painters of the European Renaissance wanted to show beautiful, powerful women, they portrayed women with rolls of fat and rounded curves. In some cultures today, larger women are still seen as having ideal body shapes and greater weight is associated with perceived fertility. When resources are scarce, having greater weight is often a sign of wealth because it shows that the household has more than enough calories and does not have to expend so many of them in physical labor. On the other hand, the women who model on the fashion runways in Paris and Milan and those who are Hollywood stars tend to be extremely skinny. In industrialized societies, being underweight is often an indication of wealth because richer households have the time and money to prepare healthy foods and exercise whereas working-class households rely on cheap fast foods and work long hours at jobs that are often sedentary.

However, globalization is influencing attitudes toward food and body image. Although eating disorders like anorexia nervosa and bulimia nervosa are still relatively rare in non-Western cultures, there are reports from many countries of cases being identified. 46 (Anorexia nervosa is a condition in which a person has a distorted body image and feels fat even when emaciated. A person with anorexia nervosa follows a very restricted diet, exercises excessively, and may use laxatives and other methods of losing weight. Bulimia nervosa is when a person engages in frequent binge- purge cycles, eating thousands of calories at one sitting then inducing vomiting and using laxatives to get rid of the calories ingested.) More importantly, dissatisfaction with body shape is becoming more common, especially as the idealized bodies of movie stars and the touched-up bodies of magazine cover models are broadcast to larger audiences. For example, recent studies of ideal body size in Pacific Island nations like Fiji, Tonga, and Samoa, which have some of the highest rates of obesity in the world, have found growing dissatisfaction with body size, a trend toward thin bodies being seen as ideal, and the beginnings of unhealthy weight loss behaviors like purging. 47- 50 Thus, attitudes toward food and perceptions about body shape are being imported and exported globally along with foods and food products.

322 CHAPTER 13 GLOBALIZATION AND HEALTH

13.5 BIOTERRORISM AND SECURITY

Bioterrorism is the deliberate release of pathogens, chemicals, or other agents that can cause illness and possibly death of people, animals, or plants. Chemical and biological warfare are not new.51 During the Tartar siege of the city of Kaffa (now in the Ukraine) in the 14th century, the bodies of plague victims were catapulted over city walls to spark an epidemic. During the French and Indian War in the 1760s, the British army sent smallpox-infected blankets to American Indians who supported the French. During World War I, several European nations used biological agents against the livestock of enemies. What is new is that there are now more tools available for creating and spreading bioterror agents and the scale on which such acts can occur is much larger.

A bioweapon may be selected because it produces severe disease or death, the target population is susceptible to the agent, and the target population has limited or no access to immunization or treatment. Additionally, a particular agent may be selected for use because it can be produced relatively easily and rapidly, is relatively inexpensive, is environmentally stable, has a low infectious dose, has a simple delivery mechanism (such as through air, water, or food), is highly infectious, has a desirable incubation period (either short so immediate disease is produced or somewhat longer so that the asymptomatic contagious stage is lengthy), and/or causes disease that is difficult to diagnose. 52 While the goal of some bioterrorists is to kill or seriously injure masses of people, the most common goal is to cause widespread fear, panic, and social disruption.

In the United States, potential bioterror agents are classified into three categories (Table 13_5).53 Category A represents high-priority agents that pose a significant risk because they can be easily transmitted from one person to another or have high mortality rates. Category A agents include anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fevers like Ebola and Marburg virus. Anthrax is of particular concern because it was used in a postal bioterrorism attack in the United States in 2001.5~,55 Naturally occurring cases of anthrax (Bacillus anthracis) are diagnosed every year in people who work with sheep and livestock because anthrax forms spores (dormant bacteria) that can survive in the environ- ment for years. These cases are usually skin (cutaneous) infections. In the laboratory, anthrax can be made into a fine powder, creating an inhalational anthrax that affects the lungs. Anthrax is not passed from person to person, but the weaponized form can be aerosolized and breathed in. The disease

13.5 Bioterrorism and Security 323

Table 13"05 U.S. classifications of potential bioterrorism agents.

Category

Nerve agents

Blood agents

Blister agents

Heavy metals

Volatile toxins

Pulmonary agents

Incapacitating agents

Explosive nitro compounds and oxidizers

Flammable industrial gases and liquids

Poisonous industrial gases, liquids, and solids

Corrosive industrial acids and bases

Other agents

Examples

tabun, sarin, soman, GF, VX

hydrogen cyanide, cyanogen chloride

lewisite, nitrogen and sulfur mus- tards, phosgene oxime

arsenic, lead, mercury

benzene, chloroform, trihalomethanes

phosgene, chlorine, vinyl chloride

ammonium nitrate combined with fuel oil

gasoline, propane

cyanides, nitriles

nitric acid, sulfuric acid

esticides, dioxins, furans, polychlori- nated biphenyls (PCBs)

Source: Adapted from Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. 2000;49(RR-1):1-14.

13.6 Global Environmental Change and Health 325

of essential vaccines and medications. 53 Strong communication systems are also necessary for keeping the public informed of developments and encouraging appropriate personal responses. Global communication may also playa key role in preventing some acts of terrorism and responding to attacks that do occur.

A recent study estimated that about 24% of the global disease burden can be attributed to environmental factors such as water, sanitation, indoor and outdoor air pollution, noise, housing risks, chemicals, the recreational environment, water resources management, land use and the built environ- ment, radiation, and occupational exposures 57 Many of these diseases could be prevented with modest environmental interventions. For example, digging pit latrines reduces the incidence of diarrhea and also keeps feces from contaminating water supplies. And vector control, such as spraying insecticide to reduce the mosquito popUlation and the incidence of malaria, can be minimally damaging to the environment if the chemicals are applied correctly.

Infrastructural development-building permanent structures, terracing slopes for agricultural use, converting forests to farms, paving streets, installing electric lines and sewers, building dams, extracting fossil fuels to make oil and other petroleum products, and a host of other activities-has increased the quality of life for billions of people. Many of these environ- mental changes are beneficial for health and have minimal impact on the environment. However, any environmental change may also create a new set of health concerns 58-60

The immediate effects of most human activities are local, but the distinc- tion between local and global environmental change is getting blulTier. The air pollution created by millions of commuters driving to work each day in one city does not just damage their airspace, but that of their neighbors. The solid waste products, including hazardous materials, that are produced in one country may be transported across national boundaries as rich countries pay others to take on the long-term environmental risk of storing potentially toxic waste. 61 Deforestation and habitat destruction, soil erosion and salini- zation, water management problems, overhunting and overfishing, invasive species (which may crowd out local flora and fauna), human population growth, and increasing use of resources per capita can all have local and global impacts. 62

326 CHAPTER 13 GLOBALIZATION AND HEALTH

Table 13-7 Percent of disease attributable to environmental risk factors.

% of Cases Primary Environmental Attributable to Risk Factor (>25% of Cases

Disease the Environment Attributable to the Risk Factor)

Intestinal nematode 100% Water, sanitation, and hygiene infections

Trachoma 100% Water, sanitation, and hygiene

Schistosomiasis 100% Water, sanitation, and hygiene

Japanese encephalitis 95% Water resources management

Dengue 95% Housing risks

Diarrheal diseases 94% Water, sanitation, and hygiene

Drowning 72% Recreational environment

Unintentional poisonings 71% Chemicals

Lymphatic filariasis 66% Water, sanitation, and hygiene

Chagas disease 56% Housing risks

Malnutrition 50% Water, sanitation, and hygiene

Lower respiratory 42% Indoor air pollution infections

Malaria 42% Water resources management

Road-traffic accidents 40% Land use and built environment

Source: Data from Pruss-OstOn A, Corvalan C. How much disease burden can be prevented by environmental interventions? Epidemiology. 2007;18:167-178.

Globalization can also benefit environmental health by encouraging the use of sustainable practices. In a global marketplace, the choices any person makes about where to live, work, and travel, and what to purchase, can have a significant influence on others around the world. For example, the growing demand for organic foods and other organic products in high-income countries has created an incentive for farmers to minimize the use of chemicals on their crops. As a result, a growing number of farmers in countries of all income levels have adopted new growing techniques. 63

Table 13-8 Examples of health effects of local environmental change.

Environmental Change Possible Pathways

Dam building and Increased snail habitat and human contact with water

irrigation Increased insect breeding sites

Increased moist soil

Urbanization

Deforestation

Lack of access to clean drinking water and sanitation for residents in low-quality housing areas

Increased trash that attracts rodents

More Aedes aegypti mosquito breeding sites

Crowded housing

Immigration of susceptible people

Increased insect breeding sites

Increased contact with animal reservoirs

Possibly Increased Disease Outcomes

Schistosomiasis

Vectorborne infections

Helminth infections

Diarrheal diseases and helminthiases

Plague, hantavirus

Dengue

Mental illness, wariviolence, tuberculosis and respiratory infections

Communicable diseases

Vectorborne infections

Zoonotic infections

Reforestation Increased contact with tick vectors and increased outdoor Lyme disease exposure

Agricultural intensification

Increased antibiotic and pesticide use promotes drug and insecticide resistance

Increased contact with vectors

Poisoning, vectorborne infections, drug-resistant infections

Vectorborne infections

Source: Information from Moore M, Gould P, Keary BS. Global urbanization and impact on health. Int J Hyg Environ Health.

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2003;206:269-278; and Wilson ML. Ecology and Infectious Disease. In: Aron JL, Patz JA, editors. Ecosystem change and public w health. Baltimore MD: The Johns Hopkins University Press; 2001; and Global environmental outlook year book 200412005. tj Nairobi, Kenya: UNEP; 2005.

328 CHAPTER 13 GLOBALIZA TION AND HEALTH

However, the cumulative effect of the intensified use of natural resources across the planet appears to be contributing to global climate change. The Intergovernmental Panel on Climate Change (IPCC), which reviews and synthesizes scientific data about climate and weather, has expressed cer- tainty that global warming is occurring and will continue to occur for cen- turies to come. The IPCC has also concluded that the observed changes are very likely due to human activity.64 The impacts of global climate change include land degradation, water and air quality issues, a loss of biodiversity, and temperature and precipitation extremes (Figure 13_5),65 all of which can have a significant impact on human health.66

While cycles of climate change have occurred throughout history, there is growing concern about the pace of global warming. The IPCC predicts that climate change will mean more frequent hot days and nights and fewer cold days and nights, an increasing frequency of heat waves, an increase in the frequency of heavy precipitation events in some areas and an increase in droughts in others, an increase in tropical cyclone (hur- ricane) activity, and an increase in the incidence of extremely high sea levels. 64 In addition to temperature extremes and variable weather cycles, there may be continued ozone depletion and increased ultraviolet radia- tion. Global warming can also lead to acid precipitation (acid rain), loss of biodiversity, desertification, and resource depletion (such as the loss of potable water supplies). These changes can have direct effects on human health (Table 13_9).67

Figure 13-5 Examples of the signs of global environmental change.

13.6 Global Environmental Change and Health 329

Tab~e 13-9 Examples of human health effects of global climate change.

Diseases

Asthma and allergies

Skin cancer and cataracts

Cardiovascular disease

Nutritional diseases

Mental health

Infectious diseases

Mechanism

Changes in air quality (due to increased pollen, mold, toxins, or dust) may increase the preva- lence and severity of respiratory diseases

Increased exposure to ultraviolet radiation (due to a decrease in stratospheric ozone) may increase the incidence of skin cancer and cataracts

High temperatures and poor air quality increase the incidence of heart attacks and strokes

Changes in temperature and precipitation can reduce crop yields and lead to undernutrition

The stresses associated with extreme weather events could increase the incidence and severity of psychological disorders

Climate change has the potential to increase the incidence of vectorborne (insect-transmitted) and zoonotic (animal) diseases as well as waterborne diarrheal diseases

Source: Information from The Interagency Working Group on Climate Change and Health. A human health perspective on climate change: a report outlining the research needs on the human health effects of climate change. Research Triangle Park NC: Environmental Health Perspectives/National Institute of Environmental Health Sciences (NIEHS); 2010.

Climate change will affect every individual, community, and nation. Heat waves in the United States, Europe, India, and other regions of the world have already been responsible for the deaths of older adults and those with respiratory diseases. 68 Each year, floods cause the deaths of thousands of people and animals, destroy homes and crops, and damage infrastructure, including hospitals, roads, and sewage systems. 69 The poor bear the highest burden, because most of the deaths from extreme weather occur in low-income areas. 70

Regardless of arguments about the precise causes of global warming, these alarming trends support the notion that humans should try to tread more lightly on the Earth. For example, alternative energy sources that

330 CHAPTER 13 GLOBALIZA TION AND HEALTH

harness solar, wind, or wave power may be able to produce energy that creates less pollution and less environmental damage than carbon-based fuels, hydroelectric power (which requires the building of massive dams and flooding of large swaths of land), and nuclear power (which remains dangerous because of the risk of a meltdown). The short- and long-term risks and benefits of projects that alter the environment should be care- fully considered before projects are initiated, and the assessments should include health and environmental evaluations as well as economic consid- erations. Preventive measures should be implemented, such as using locally appropriate building materials and housing styles and not building homes in especially vulnerable 10cations.71 Additionally, global monitoring and communications systems need to be strengthened so that potentially cata- strophic events like widespread famines can be prevented and addressed.66

In a globalized world, everyone has a stake in creating and sustaining a healthyenvironment.72

13.7 DISCUSSION QUESTIONS

1. How is globalization beneficial for individual and public health? How is globalization harmful?

2. If you were a poor resident of a low-income country, would you rather live in a rural area or an urban area? Why?

3. How worried should humans be about the emergence of new infec- tious diseases? Is there anything that we can do to reduce the risk ofEIDs?

4. What are some examples of recent foodbome outbreaks? What were the food sources that spread the infection? Was global trade a factor in these outbreaks?

5. Describe the physical characteristics that make a man or woman attrac- tive in your culture. How have your own ideals about beauty been shaped by culture?

6. What do your state/province and/or country recommend that you do to prepare for a possible act of bioterrorism? Have you taken the recom- mended steps? Why or why not?

7. What changes in the natural and built environments of your commu- nity have increased the health of local residents? What changes have decreased the health of the community?

8. What steps can you take to minimize your ecological footprint?

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59. Wilson ML. Ecology and Infectious Disease. In: Aron JL, Patz JA, editors. Ecosystem change and public health. Baltimore MD: The Johns Hopkins University Press; 2001.

60. Global environmental outlook year book 200412005. Nairobi, Kenya: UNEP; 2005. 61. Liddick D. The traffic in garbage and hazardous wastes: an overview. Trends Organized

Crime. 2010;13:134-146. 62. Diamond J. Collapse: how societies choose to fail or succeed. New York: Viking; 2005. 63. Willer H, Kilcher L, editors. The world of organic agriculture: statistics and emerging

trends 2012. Bonn, Germany: International Federation of Organic Agriculture Movements; 2012.

64. Intergovernmental Panel on Climate Change. Climate change 2007: the physical science basis. Summary for policymakers. Geneva: IPCC; 2007.

65. Rockstrom J, Steffen W, Noone K, et al. A safe operating space for humanity. Nature. 2009;461 :472-475.

66. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change. Lancet. 2009;373:1693-1733.

67. The Interagency Working Group on Climate Change and Health. A human health perspective on climate change: a report outlining the research needs on the human

334 CHAPTER 13 GLOBALIZATION AND HEALTH

health effects of climate change. Research Triangle Park NC: Environmental Health Perspectives/National Institute of Environmental Health Sciences (NIEHS); 2010.

68. Kovats RS, Hajat S. Heat stress and public health: a critical review. Annu Rev Public Health. 2008;29:41-55.

69. Alderman K, Turner LR, Tong S. Floods and human health: a systematic review. Environ Int. 2012;47:37-47.

70. McMichael AJ, Friel S, Nyong A, Corvalan C. Global environmental change and health: impacts, inequalities, and the health sector. EMf. 2008;336:191-194.

71. Frumkin H, Hess J, Luber G, Malilay J, McGeehin M. Climate change: the public health response. Am f Public Health. 2008;98:435-445.

72. McMichael AJ, Beaglehole R. The changing global context of public health. Lancet. 2000;356:495-499.

CHAPTER 14

Health, Human Rights, and Humanitarian Aid

14.1 HEALTH AND HUMAN RIGHTS

The preamble to the Constitution of the W orId Health Organization (WHO), which has been affirmed by the nearly 200 countries that have membership in the United Nations (UN), lists nine health principles (Table 14-1). The boldest claim is that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being." 1 This statement calls for the standard of health to be raised so that everyone has access to at least basic medical and psychological care (principle 7), especially people who are members of vulnerable population groups (principles 2 and 6). The preamble also notes that health is linked with peace (principles 3, 4, and 5), that areas with poor health standards put everyone at risk for outbreaks of infectious disease (principle 5), and that both the public (principle 8) and governments (principle 9) must take active responsibility for public health. Two key terms require careful definitions: human rights and standard of health.

A human right is an entitlement that is due to every person simply because of being human. Human rights are considered to be universal (available to everyone) and irrevocable (something that cannot be taken away). Many of these rights are spelled out in the Universal Declaration of Human Rights (UDHR), which was unanimously adopted by the member

335

336 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN Am

Table "14~1 Health principles from the Preamble to the Constitution of the World Health Organization.

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

2 The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition.

3 The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and States.

4 The achievement of any State in the promotion and protection of health is of value to all.

5 Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

6 Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development

7 The extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health.

8 Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people.

9 Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.

Source: Reproduced from the World Health Organization. The Constitution of the World Health Organization. hUp://whqlibdoc.who.intihistiofficiaUecords /constitution .pdf.

states of the UN in 1948 2 Articles 3 to 21 define civil and political rights that protect the foundational freedoms of humans, such as the right to privacy and the right to freedom from torture. These rights are about protections rather than provisions, and they can be granted and upheld with limited financial costs to the government. Articles 22 to 28 outline economic, social, and cultural rights that, if realized, would contribute to human flourishing. These rights, such as the right to social security, the right to education, and the right to a standard of living adequate for health and well-being, obligate governments to provide certain services to their people. 3

14.1 Health and Human Rights 337

Table 14-2 Human rights listed in the Universal Declaration of Human Rights.

Human Right

Right to equal dignity and human rights for all humans

Right to life, liberty, and security of person

Freedom from slavery and servitude

Freedom from torture and cruel, inhuman, or degrading treatment or punishment

Freedom from discrimination

Freedom from arbitrary arrest, detention, or exile

Right to a fair trial

Right to privacy

Freedom of movement

Right to asylum

Right to a nationality

Right to marry and found a family

Right to own property

Freedom of thought, conscience, and religion

Freedom of opinion and expression

Freedom of peaceful assembly and association

Right to participate in government

Right to social security

Right to work

Right to rest and leisure

Right to a standard of living adequate for the health and well-being of the individual and his/her family, including food, clothing, housing, medical care, and necessary social services, and the right to security in the event of unemploy- ment, sickness, disability, widowhood, or old age

Right to education

Right to participate in the cultural life of a community

UDHR Articles

1,2,6

8, 10, 11

Source: Adapted from United Nations Human Rights. The Universal Declaration of Human Rights. http://www.ohchr.org/en/udhr/Pages/UDHRlndex.aspx.

338 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

The standard of health refers to targets that governments set for improv- ing the health of their populations. The UN High Commissioner for Human Rights has clarified what is meant by the right to the "highest attainable standard of health": "The right to health does not mean the right to be healthy, nor does it mean that poor governments must put in place expen- sive services for which they have no resources. But it does require gov- ernments and public authorities to put in place policies and action plans [ which] will lead to available and accessible healthcare for all in the short- est possible time. To ensure that this happens is the challenge facing both the human rights community and public health professionals.,,4 In other words, no one can guarantee health for anyone-many diseases have no known preventable cause and no known cure-but governments can strive to increase access to preventive and therapeutic services, starting with a basic package of health care services (such as antenatal care, childhood vac- cinations, treatment for common infectious diseases, and access to clean water) and then expanding the range of services that are available to the whole population.5

The goals of the field of health and human rights include exposing human rights violations, increasing accountability for governments and other orga- nizations involved in health and human services, providing education about rights, and improving access to health and related services. 6 Achieving the highest attainable standard of health requires increasing access to health care and to the tools for health.

14.2 ACCESS TO HEALTH

Access to health is a major economic and political concern in most countries. In the United States, recent changes in healthcare policy have sparked debates about how to increase the proportion of the population with health insurance, contain rising healthcare costs, and regulate private health insurance plans, and whether to expand government healthcare coverage to include those who are not poor, old, or government employees.7

Brazil is trying to reduce remaining health disparities by increasing rev- enue for its universal public healthcare system and improving the quality of services provided. 8 China is seeking to increase medical insurance coverage, to ensure access to essential medications, and to invest more resources in primary health care and preventive health services. 9 India is pursuing options for reducing the high out-of-pocket healthcare expenses that restrict access to health services for low-income households. lO

14.2 Access to Health 339

Sierra Leone introduced free maternal and child health care at public facilities in 2011, and is now trying to figure out how to pay for the plan. ll

Every country has to make decisions about what healthcare services should be provided and who should pay for those services, and these decisions have human rights implications.

A first major access to health issue is whether health care should be seen as a basic social right or if it should be treated like a commodity that can be bought and sold. l2 Some countries have national constitutions or laws that recognize the right to health. 13 These countries, which include Brazil and Poland, typically have healthcare systems that provide universal (or nearly universal) health care that is funded through tax revenue. 14,15 Everyone in these countries has access to a package of essential health services at no cost to them beyond what they pay in taxes. Other countries have healthcare systems that are primarily private. A package of free or subsidized essential healthcare services may be provided to children and low-income adults by the government, but some critical health services may cost too much to be accessed by these households. Human rights activists say that if health is a human right it is unjust that poor people so often do not have access to even the minimum level of health care that will allow them to live healthy and productive lives, especially as most poor people are born into poverty. 12

Given that every country has limited resources available for health, a related issue is about the package of healthcare services that should be available to everyone. The right to health does not mean the right for everyone to have access to every health resource on demand. Difficult decisions have to be made about how to prioritize distribution of health goods and services, like deciding who will be eligible for a particular sur- gery, which medications will be part of the health system's formulary, and which routine preventive health services and screenings will be covered. The unfortunate reality is that most health systems cannot provide a heart transplant to everyone who needs one to stay alive, high-tech and expensive cancer treatments for everyone who would benefit from them, or years of intensive rehabilitation for everyone whose quality of life would improve with more extensive therapy. Judgments about what health systems will cover have to consider the number of medical specialists and support staff available to do procedures, the types of healthcare facilities available, the cost-effectiveness of various medicines and health technologies, and the improvements in quality of life associated with various interventions. 16

However, the general consensus is that the right to health includes the right to access at least basic healthcare services, essential medications and health technologies, and water and other foundational resources for health.

340 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

14.2.A Access to Health Care

The right to health care is one of many human rights recognized in the Universal Declaration of Human Rights. Article 25 states that "everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services.,,2

Several key criteria are used to evaluate access to health care: 17

• Availability: There should be an adequate number of medical and public health facilities that are functioning, staffed, and stocked with the necessary supplies.

• Accessibility: Health care should be geographically and physically accessible to everyone, regardless of residential location and physical ability.

• Affordability: Health care should be economically accessible. Payment for services should be commensurate with ability to pay.

• Acceptability: Health care should be respectful of patients from all ethnicities, sexes, ages, and other population groups. This may mean adapting to cultural expectations, such as ensuring that a female healthcare provider examines female patients in nonemergency situ- ations if that is the cultural expectation of the patient.

• Quality: Health facilities should be well maintained and stocked with appropriate supplies, and healthcare staff should be appropriately skilled.

These set a minimum standard for access to health care. They do not specify what constitutes an appropriate level of access to health personnel, medical specialists, tests and procedures, medications, and health technol- ogy because access is dependent on a country's resources. Lower-income countries generally have lower standards of health because they have more limited resources. Those limits include too few healthcare workers (Table 14_3),18 a situation exacerbated by "brain drain," the migration of healthcare professionals trained in low-income countries to higher paying jobs in high-income countries. 19 Ideally, every country should be working toward increasing access to and quality of health personnel and services.

14.2.B Access to Medication

Creating and testing new medications is a long and expensive process costing about $1 billion, on average, for each new product. 2o In exchange for their research and development (R&D) investments, pharmaceutical

Table 14-3 Healthcare personnel and services per 10,000 people in 2010.

Country USA South Korea Poland Brazil China India Kenya Sierra Leone

Physicians 24.2 20.2 21.6 17.6 14.2 6.5 0.2

Psychiatrists 0.8 0.5 0.5 0.3 0.1 <0.05 <0.05 <0.05

Nurses/midwives 98.2 52.9 58.0 64.2 13.8 10.0 1.7

Dentistry personnel 5.0 3.2 11.7 0.4 0.8 <0.05

Pharmaceutical 12.1 6.3 5.4 2.5 5.2 0.3

personnel

Community health 8.3 0.5 0.2 .......

workers :I:>.. N

Hospital beds 30 103 67 24 42 9 14 ~ C"") C"")

Psychiatric hospital ~ 3.4 19.1 5.4 1.9 1.4 0.2 0.3 '" beds '" cs-

--: data not available ~ \:) '-

Source: Data from World health statistics 2012. Geneva: WHO; 2012. ~

w +>-......

342 CHAPTER14 HEALTH,HUMANRIGHTS, AND HUMANITARIAN AID

companies with a new product that has been shown to be safe and effective are granted a patent for the drug and given exclusive rights to sell that drug for at least five years (and often much longer that that).21 Generic versions of the patented drug cannot be sold legally until after the expiration of the exclusivity period. This provides the company with a window of opportu- nity in which to recoup R&D costs and possibly make a profit.

International trade agreements from the World Trade Organization (WTO) , a UN agency, enforce the patents issued by member nations (Table 14-4). For example, the TRIPS (Trade-Related Aspects of Intellectual Property Rights) agreement standardized intellectual property laws. The World Intellectual Property Organization (WIPO) also protects patents, copyrights, and registered trademarks, including those for health- related products. Additionally, bilateral and multilateral trade agreements between two or more countries may include clauses that further restrict access to cheaper drugs. (These are sometimes called "TRIPS Plus" agree- ments because they require more protections on intellectual property than TRIPS does.) For example, trade agreements might extend the duration of a patent on a pharmaceutical agent and enforce rules that prohibit generic versions of the drug from being produced or imported. These agreements may inhibit the ability of low- and middle-income countries to take action to procure or to produce their own cheaper medications.

Table 14-4 Health aspects of international trade agreements.

Trade Agreement

General Agreement on Trade in Services (GATS)

General Agreement on Tariffs and Trade (GATT)

Trade-Related Aspects of Intellectual Property Rights (TRIPS)

Health Aspects

Treats human services such as health care, water, sanitation, and education as commodities subject to trade rules. Also addresses some safety regula- tions, handling of hazardous materials, licensing of medical practitioners, and other aspects of health.

Allows for countries to ban certain products to protect public health, but directs more attention to protecting intellectual property rights like drug patents.

Protects patents, copyrights, trademarks, and industrial designs across national boundaries and, therefore, limits the production of certain protected medications. Contains safeguards that are sup- posed to ensure access to essential medications.

14.2 Access to Health 343

Many of the concerns about access to essential medicines came to light as a result of the unmet need for low-cost antiretroviral drugs (ARVs) to combat HIV/AIDS in Africa. 22 As the HIV/AIDS pandemic expanded in the 1990s, the new ARVs that were saving lives in high-income countries were too expensive to be widely used in low-income regions. Countries like Brazil, India, and South Africa that tried to produce generic ver- sions of patented ARVs (or to import generic drugs produced elsewhere) faced penalties for violating international intellectual property regula- tions. In the early 20008, pharmaceutical companies, ministries of health, and advocacy groups worked together to make patented drugs available at a lower price to low-income countries, and the WTO clarified that the TRIPS agreement "should be interpreted and implemented in a man- ner supportive of WTO members' right to protect public health and, in particular, to promote access to medicines for all.'m Countries fac- ing a "national emergency or other circumstances of extreme urgency" could issue "compulsory licenses" for drugs to be manufactured locally. (However, restrictions still applied to imported medications, and few low- income countries had manufacturing capabilities.) By 2010, the Global Fund, PEPFAR (the U.S. President's Emergency Plan for AIDS Relief), and other programs had helped to significantly increase the proportion of people with HIV infection worldwide who were taking ARVs, and the majority of the ARVs were generics. 22

HIV medications are not the only drugs with limited availability in low-income countries, and other initiatives are seeking to increase access to a variety of critical pharmaceutical agents. For example, the Medecins Sans Frontieres (Doctors Without Borders) Campaign for Access to Essential Medicines is lobbying for lower prices, limits on patents, and the develop- ment of new diagnostic tests and medicines for common infectious diseases and neglected tropical diseases. 24

Additionally, to avoid the issue of patent protection entirely, public- private partnerships, which are often funded by philanthropic organizations, have been formed to develop new drugs for neglected tropical diseases. 25

These partnerships usually target drugs for diseases that for-profit compa- nies are unlikely to invest in because of the limited revenue expected from a product created solely for use in low-income regions. Drugs produced by these partnerships will be available at a low cost as soon as they are proven to be safe and effective.

However, significant inequalities in access to medications remain. The WHO's core list of essential medicines that healthcare systems should stock includes about 800 anti-infective, anti-allergic, analgesic, antipsychotic, and

344 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

hormonal drugs along with medications for noncommunicable diseases such as epilepsy, migraines, heart disease, asthma, and gastrointestinal diseases. 26 The typical low- or middle-income country only includes about 400 medications on its national essential medicines list, about half of the drugs recommended by the WHO expert panel.27 In contrast, the typical high-income country has a formulary with more than double the number of drugs on the WHO list.

As a result, people in high-income countries have much greater access to medications than people in other parts of the world (Figure 14-1). On average, people in high-income countries spend about $432 per year on medications (public and private spending combined), compared to $84 in upper middle- income countries, $31 in lower middle-income countries, and $8 in low-income countries (Figure 14-2).28 High-income and low-income countries are home to sirnilarproportions of the world's population (16% and 17%, respectively), but high-income countries make 78.5% of global pharmaceutical purchases, while low-income countries account for only 1 % of sales.29

14.2.C Access to Health Technology

Breaking the cycle of disease and poverty requires increased access to health technologies-such as medications, vaccines, and bednets, and also water filters, solar cookers, and other assistive devices-but many

Population

III High income

III Upper middle income

III Lower middle income

D Low income

Pharmaceutical Expenditures

Figure 14-1 Total population and global pharmaceutical sales by country income level in 2006.

Source: Data from Lu Y, Hernandez P, Abegunde D, Edejer T. Medicine expenditures. In: The world medicines report. Geneva: WHO; 2011.

14.2 Access to Health 345

$1200,-------------------------------------------------,

$1054

$1000

$800

$600

$400

$200

$11 $-

$9 $7

USA South Poland Brazil China India Kenya Sierra Korea Leone

14"-2 Pharmaceutical sales per person ($U.S.) in 2010.

Source: Data from The pharmaceutical industry and global health: facts and figures. Geneva: International Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2011.

of the health tools that are effective and relatively affordable remain prohibitively expensive for the poorest households. Simple interventions like insecticide-treated bednets and multivitamins could be adopted for wider use if the global community had the collective will to see that these lifesaving technologies are distributed at low or no cost to the people who need them most.

Thus, the product development cycle for technology for global health does not end when a product is completed and has been field tested. The technology must also be made available for widespread use. The Bill & Melinda Gates Foundation, which makes large donations to researchers creating new technologies for health, recognizes this progression with a four-step process of discovery, development, delivery, and advocacy (which is aimed at sustainability and public policy)?O The "delivery" phase requires an organizational structure to be in place in the field to coordinate dis- semination efforts. Additionally, the technology must be easily and reliably available to those who have chosen to use it, it must be affordable, and it must gain local acceptance and be adopted for use by the end user and not just the national government. 3 ! In other words, technology is necessary for improving health, but the existence of a helpful tool for health is not enough. A tool only becomes helpful for global health when the people who

346 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANIT ARIAN AID

would benefit most from it have access to it and choose to use it. Access to new technologies requires product advocacy and buy-in from a variety of stakeholders, including donors, policymakers, and end users.31

14.2.D Access to Water

Because water is a basic human need-something like air that everyone requires on a daily basis just to survive-access to water is a human right.32

This does not mean that everyone has a right to an unlimited amount of free water. It does mean that everyone has a right to an adequate quantity of clean water for consumption and hygiene (about 20 to 50 liters daily) at a reasonable cost. 33

Increasing access to water requires investments in water system infra- structure, which usually means digging new groundwater wells and pro- tecting surface water sources, installing miles of pipelines and pumps to transport water from the source to consumers, and sometimes also con- structing facilities to store and treat the water. These improvements can be expensive, and the costs of building and maintaining the water system must usually be recouped through taxes or user fees. Additionally, user fees help promote conservation, which is important in places where freshwater resources are limited. Thus, water is now considered to be both a consumer good and an essential human need.34 These sometimes contradictory defini- tions have at times led to significant tensions.

One concern is about the ability of poor households to afford the water they need, especially following water privatization. For example, massive protests occurred in 2000 in Cochabamba, Bolivia's third largest city, after the government leased the city's water rights to a U.S.-based corporation in order to improve services and to satisfy a condition of a World Bank loan. 35

In order to raise capital for modernizing the water system, the company significantly increased user fees. For many low-income households, the higher cost of water was a huge burden. There was no legal way to reduce the cost of the household's water, because residents were banned from using other water sources, such as personal wells and storage tanks, and were even forbidden to collect rainwater without a paid permit. 36 After several months of escalating protests, the water system was renationalized. However, other countries in Latin America, Asia, Africa, and other parts of the world are now experimenting with water privatization. 37 Concerns remain about how to ensure that the poorest residents do not suffer under new policies, and about what alternatives exist for increasing access to safe drinking water.

14.3 Disasters and Health 347

A related set of questions exist about ownership of various water resources, especially in areas where a growing human population and agri- cultural intensification have placed extreme demands on the watershed. For example, water supplies are becoming a crucial issue in the American West. In many of the western states, water rights sold (often many decades ago) to cities, farmers, ranchers, and miners define who owns various supplies of water. As was the case in Cochabamba, rainwater collection by those who do not own rights to the local watershed is illegal. 38 Thirsty cities like Los Angeles and Las Vegas that require additional water for their grow- ing populations have to purchase water rights from increasingly remote sources, which may result in the water from distant rivers being rerouted to the city. In some cases, diversion of water or excessive use of water by upstream consumers has left those downstream with a much reduced supply of water?9 It can be difficult for those downstream populations to make a legal case for their right to the missing water, especially if the water crosses a state or national border (such as the U.S.-Mexican border). The growing concerns about water scarcity require conservation of precious water resources (including the reduction of water loss during transport), clarification of the laws that govern water markets and water use, and a commitment to ensuring adequate water access to vulnerable populations.

14.3 DISAST]~R§ HEALTH

Both natural and human-generated disasters can lead to urgent humani- tarian situations Cfable 14-5). The critical needs immediately after any humanitarian incident include (1) water supply, sanitation, and hygiene ("WASH"); (2) food security and nutrition; (3) shelter and essential non- food items such as personal care items, clothing, bedding, cooking and eating utensils, fuel, and lighting; and (4) essential health services for com- municable diseases, sexual and reproductive health, injuries, mental health, and noncommunicable diseases.4o After attending to urgent and immediate needs, response efforts typically shift from relief activities toward recovery and reconstruction.

The players involved in a particular humanitarian response depend on the scale of the incident (Tablc§ 14-6 and 14·~7).41,42 A crisis is a small-scale event that can easily be addressed locally, like when a tornado damages several homes in a small town and neighbors provide aid to the affected households. An ernergency is a larger event that stresses local resources but can still be managed locally. A occurs when the

348 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

Table 14-5 Examples of types of disasters.

Natural Disasters

Weather-related disasters

• Floods

• Landslides/mudslides

• Hurricanes/cyclones/typhoons

• Tornadoes

• Winter storms

Geophysical disasters

• Earthquakes

• Tsunamis

• Volcanic eruptions

Climate-related disasters

• Droughts

• Extreme heat

• Extreme cold

• Wildfires and forest fires

Biological disasters

• Pandemic disease

• Insect infestations

Table 14-6 Scale of critical incidents.

Human-Generated Disasters

Intentional

• War • Genocide/ethnic cleansing

• Terrorism

• Refugee crises

• Internally displaced persons (lOP) crises

Nonintentional

• Transportation accidents

• Industrial accidents

• Hazardous materials spills

• Explosions/fires

• Radiation

• Structural collapses (buildings, bridges, dams, tunnels)

crisis capacity> demand local response is sufficient

2 emergency capacity = demand local response is sufficient

3 disaster demand> capacity outside assistance is necessary

4 catastrophe demand> > capacity extensive outside assistance is necessary

Source: Information from Quarantelli EL. Just as a disaster is not simply a big accident, so a catastrophe is not just a big disaster. J Am Soc Professional Emerg Planners. 1996; 3: 68-71.

need for assistance exceeds local capacity. A catastrophe overwhelms the local response network and requires extensive outside assistance, as was the case following the earthquake in Haiti in 2010 and the tsunami in Southeast Asia in 2004.

14.3 Disasters and Health 349

Table 14-7 PICE (potential injury-creating event) nomenclature.

Projected Potential for Effect Extent of Need for Status of

PICE Additional on Local Geographic Outside Outside Stage Casualties Resources Involvement Assistance Help

0 static controlled local little to none inactive

dynamic disruptive regional small alert

2 dynamic paralytic national moderate standby

3 dynamic paralytic international great dispatch

Source: Information from Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature-a functional impact approach: the PICE system. Acad Emerg Med. 1996;3:723-727.

In any response, careful attention must be paid to protecting the civil, political, economic, social, and cultural rights of affected persons. In some situations, individual and collective rights must be balanced. A is a human right that is irrevocable, such as the rights to freedom from slavery and freedom from torture. But some other rights may be temporarily suspended under special circumstances when restrictions on some individual rights protect the community as a whole. For example, freedom of movement for people with highly contagious infections may be temporarily limited during an epidemic so that the right of other people to health can be protected. 43 If rights are derogated during or immediately after a critical incident, the new rules must not be discrimi- natory, and full rights should be restored as soon as possible. Communities engaged in civil conflicts and wars, hosting refugees and internally dis- placed persons, beginning postconflict recovery, or damaged by natural disasters all face special health and human rights concerns.

A complex human.itarian emergency occurs when civil conflict or war cause mass migration of civilian populations, food insecurity, and long- term public health concerns.44 Unlike natural disasters, which usually cre- ate an immediate period of acute need but quickly transition into recovery mode, complex humanitarian emergencies may remain in an acute phase for years or even decades. International humanitarian laws are supposed to provide protection to civilians and armed forces, but these rules are not

350 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

always enforced.45 For example, rape and sexual violence have become military tactics in many recent conflicts.46

Malnutrition is a primary concern during conflicts.47 Food produc- tion tends to decrease as farms are abandoned, and it is more difficult to import affordable food during times of instability. Food supply chains- processing, transportation, storage, sales-are often interrupted by conflict and uncertainty. And large numbers of people may be migrating and in need of a daily supply of nutrients. The combination of too few calories and micronutrients plus other diseases often leads to severe undernutrition.

Outbreaks of communicable diseases also often occur during complex emergencies, in large part because of the breakdown of social services, including water and sanitation services and public health services. Diarrheal diseases are very common. Other concerns include measles (because of lack of vaccination), respiratory infections like pneumonia and tuberculosis (associated with inadequate shelter), meningitis and malaria (in endemic areas), hepatitis, and sexually transmitted infections (which may have resulted from gender-based violence and may remain untreated because of lack of access to health care).48 Reproductive health services, includ- ing family planning and obstetric care, and psychiatric services tend to be severely inadequate during conflicts.

14.3.B Refugees and Internally Displaced People

A refugee is a person who has been forced to involuntarily move because of security concerns like war, civil conflict, political strife, or per- secution based on race, tribe, religion, political affiliation, or membership in some other group. There were about 10 million refugees worldwide at the end of2011.49 At the beginning of a refugee migration, UNHCR (the office of the UN High Commissioner for Refugees) and other humanitar- ian organizations, both governmental and private, attempt to provide for the basic needs of refugees, including shelter, food, water, sanitation, and medical care. These services are often provided in "camps" that provide long-term shelter, especially for children, women, and the elderly. A little less than half of refugees live in camps; the rest are displaced to cities or rural areas, where they live alongside residents and other types of migrants and may not have access to special services for refugees.50 The long-term goal is to find durable (lasting) solutions by helping refugees to repatriate if possible, or to integrate into their countries of asylum or resettlement.

14.3 Disasters and Health 351

To be classified as a refugee by the UN, a person must have crossed an international border. An peA·§on who fled his or her home community because of civil war, famine, natural disaster, or another crisis, but did not cross into another country is not afforded the same protection and assistance. There were estimated to be more than 26 million IDPs worldwide at the end of 2011. 51 IDPs may have many of the same health needs as refugees, but UNHCR may not be able to address their problems because they have remained in their home country. IDPs usually do not live in camps; most move to new rnral areas or cities.

Refugees and IDPs share the experience of having lost their homes, jobs, social support networks, and some of their independence and sense of security_ Special health concerns are associated with different stages of the cycle which begins at the onset of migration and contin- ues until a lasting solution is implemented. Emergency interventions focus on the provision of water, food, sanitation, shelter, fuel, and health care for sick, pregnant, and vulnerable individuals. Longer-term interventions include treatment of malnutrition, addressing violence and security issues, and providing therapy for mental health problems such as posttraumatic stress disorder (PTSD).

Communities that are hosting displaced people or refugees may also have special economic and health concerns related to having new members their population. 52 One risk is that infectious disease outbreaks might occur as the host community is exposed for the first time to infectious agents car- ried by the migrant population. Another fear is that when a large number of displaced people move to one town or city, they may overwhelm the social service providers and strain the resources of the host community.

Later relief efforts focus on finding longer-term solutions to homeless- ness and displacement. lDPs and refugees who return to their horne com- munities may face challenges related to the destruction of homes, healthcare facilities, and other community buildings like schools; the loss of farmland to environmental damage and hazards like unexploded ordnance; and the displacement of their family members, neighbors, and other members of their community. Those who settle in new areas often face challenges asso- ciated with learning new cultural practices and adapting to them (a process called overcoming language and communication barriers, having limited occupational options, and potentially having limited access to health care. No matter where involuntary migrants settle, they are at risk for developing PTSD and other chronic conditions related to illnesses or injuries sustained during their displacement.

352 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

14.3.C Postconfiict Areas

In addition to rebuilding political and economic systems and restoring educational and social services after a civil conflict or war, postconflict areas need to repair health systems (because of loss of infrastructure and personnel, among other issues), expand rehabilitation services (including physical rehabilitation and mental health care), and address environmental concerns. Public health work has the potential to help with the transition back to peace by creating a sense of solidarity and strengthening social connections across diverse populations.53

Contaminated environments may take much longer to renovate than health systems.54 For example, landrnines and other unexploded ordnance buried during wartime remain hazards to workers, children, and communi- ties long after the conflict is over. This means, among many other problems, that large tracts of potential farmland are unable to be cultivated because of the risk of encountering a mine while clearing a field. Most people who sustain landrnine injuries are civilians, and children may have elevated risk because they do not know how to recognize mines and may pick them up and even play with them. Landmines remain a concern in many parts of the world (Figure 14_3).55 Although it only costs a few dollars to purchase and plant a mine, it can cost $1000 to safely remove one. 56

14.3.D Natural Disasters

People who have survived a natural disaster like an earthquake, hur- ricane, tsunami, mudslide, or major flood may have an urgent need for immediate medical treatment for injuries and for basic necessities such as water, food, and shelter, especially if a large geographic area has severely damaged infrastructure. Because natural disasters are generally seen as apolitical events, it is usually fairly easy for aid agencies to assist survivors. (This is quite different from the complicated response to complex humani- tarian emergencies, as governments and faction leaders engaged in armed conflicts are often disinclined to allow outsiders to assess and assist vulner- able populations.57)

However, if the various responders do not coordinate their efforts, the result can be chaos. In the weeks after the massive earthquake in Haiti in 2010, thousands of well-intentioned volunteers flew to Port-au-Prince to assist. But many of the volunteers were unaffiliated with a Haiti-based host organization and arrived without adequate personal supplies, so they ended up being a burden rather than a help.58 Supplies ended up being

Low, residual, or suspected contamination

Heavy contamination

II Very heavy contamination

114--3 Countries with landmine or residual duster munition contamination.

Source: Data from Landmine monitor 2011, International Campaign to Ban Landmines; 2011.

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d'tl c;;' ~ c"

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354 CHAPTER14 HEALTH,HuMANRIGHTS,ANDHuMANITARIANAm

stockpiled at the airport because the Haitian government, local institutions, and various international governmental and nongovernmental organizations had difficulty communicating about on-the-ground needs, securing local transportation, and coordinating distribution efforts. 59 Similar logistical issues have occurred after other large-scale natural disasters, including the devastating tsunami that hit Southeast Asia in 2004. 60

A well-managed international response to a natural disaster begins when an affected country invites the UN and other organizations to assist. A lead agency, often the UN Office for the Coordination of Humanitarian Affairs COCHA), is designated to coordinate the response by other UN agencies, government agencies (including militaries), the national Red Cross or Red Crescent society, and nongovernmental organizations. These groups work together to meet essential needs that have been designated as humanitarian response "clusters" 61

T:,;,tlie 14~8 Humanitarian response clusters.

Cluster Lead UN Agency

Overall Coordination OCHA

Technical Agriculture/food security FAO Clusters

Support Clusters

Camp coordination and management UNHCR/IOM

Early recovery UNDP

Education UNICEF (and Save the Children)

Emergency shelter IFRC/UNHCR

Health WHO

Nutrition UNICEF

Protection UNHCR/OHCHR/UNICEF

Sanitation, water, and hygiene (WASH) UNICEF

Emergency telecommunications WFP/UNICEF

Logistics WFP

Source: Information from Stumpenhorst M, Stumpenhorst R, Razum O. The UN OCHA cluster approach: gaps between theory and practice. J Public Health. 2011 ;19:587-592.

14.3 Disasters and Health 355

This coordination-and requiring that volunteers and their host organiza- tions complete appropriate training before traveling to the disaster site and fully provide for themselves in the field 62 -helps facilitate a rela- tively rapid and comprehensive response. National and local responses benefit from similar coordination strategies. In the United States, for example, the National Incident Management System (NIMS) spells out how different public and private sector organizations should work together to respond to a disaster, and the Incident Command System (ICS) is used in the field to provide a clear chain of command for responders.63 Fifteen "essential support functions" are covered by the national response system 63 A coordinated response can maximize use of resources and save lives.

Table '1~9 Essential support functions.

ESF #1 Transportation

ESF #2 Communications

ESF #3 Public works and engineering

ESF #4 Firefighting

ESF #5 Emergency management

ESF #6 Mass care, emergency assistance, housing, and human services

ESF #7 Logistics management and resource support

ESF #8 Public health and medical services

ESF #9 Search and rescue

ESF #10 Oil and hazardous materials response

ESF #11 Agriculture and natural resources

ESF #12 Energy

ESF #13 Public safety and security

ESF #14 Long-term community recovery

ESF #15 External affairs

Source: Information from National Incidence Management System. Washington DC: U.S. Department of Homeland Security; 2008.

356 CHAPfER14 HEALTH,HuMANRIGHTS,ANDHuMANITARIANAm

l~A EMERGENCY PREP:AREDNESS Al'JD

Emergency response is not just about responding to problems. The emer- gency management cycle includes four steps, sometimes called the "4 Rs"

9 Reduction (mitigation) of risks: Preemptive measures should be imple- mented to protect people and property from hazards (for example, by enforcing building codes).

® Readiness (preparedness): Preparation for responding to an emer- gency should include the creation and refinement of emergency operations plans, the establishment of emergency communications infrastructure, and the training of public employees and emergency response volunteers .

.. Response: The response to an imminent, ongoing, or immediately past threat should include provision of emergency medical assistance, shelter, and other critical services.

$ Recovery: During the recovery phase, continued efforts should focus on rebuilding affected communities.

Mitigating risks and preparing for potential critical incidents before they happen are the best ways to enable a smooth response and recovery when a natural or human-generated disaster does occur.

Recovery

Response

!4~4 Emergency management phases.

Reduction (Mitigation)

Readiness (Preparedness)

References 357

14.5 DISCUSSION QUESTIONS

1. Read the Universal Declaration of Human Rights. Do you agree that all of the listed items are universal human rights? Why or not?

2. What do you think should be included in a basic healthcare package that every human has access to? (In other words, what is an appropriate global "standard of health"?)

3. Who do you think should pay for a basic healthcare package for people who cannot afford to pay out-of-pocket for health services?

4. Do you think that people have the right to immediately access new medications and other health technologies at low or no cost? Why or why not?

5. The average American household spends less than 1 % of its income pay- ing for its water. What would happen in the United States if rates increased to about 20% of income, as happened in parts of Cochabamba, Bolivia?

6. What organizations in your community respond to local crises and emergencies, including those caused by natural disasters?

7. If you were being persecuted and decided that you had to leave your home to avoid torture and possible death, where would you go? How would you get there? What would you take with you? Would you try to cross a national border?

8. What natural disasters are threats where you live? How prepared are you to take care of yourself if one of these disasters occurs?

REFERENCES

1. World Health Organization (WHO). The Constitution of the World Health Organization. Accessed from http://whqlibdoc.who.int/hist/official_records/constitution.pdf.

2. United Nations Human Rights. The Universal Declaration of Human Rights. Accessed from http://www.ohchr.org/en/udhrlPages/UDHRlndex.aspx.

3. Leckie S. Another step towards indivisibility: identifying the key features of violations of economic, social and cultural rights. Human Rights Q. 1998;20:81-124.

4. Twenty-five questions & answers on health & human rights. Health and Human Rights Publication Series, Issue 1; 2002. Geneva: WHO; 2002.

5. International Covenant on Economic, Social and Cultural Rights. New York: United Nations General Assembly resolution 2200A (XXI);1966.

6. Farmer P. Pathologies of power: rethinking health and human rights. Am J Public Health. 1999;89:1486-1496.

7. Connors EE, Gostin LO. Health care refonn-a historic moment in U.S. social policy. lAMA. 2010;303:2521-2522.

8. Victora CG, BmTeto ML, do Carmo Leal M, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet. 2011;377:2042-2053.

358 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

9. Chen Z. Launch of the health-care reform plan in China. Lancet. 2009;373:1322-1324. 10. Balarajan Y, Selvaraj S, Subramanian Sv. Health care and equity in India. Lancet.

2011;377:505-515. 11. Donnelly J. How did Sierra Leone provide free health care? Lancet. 2011 ;377: 1393-1396. 12. Farmer P. Pathologies of power: health, human rights, and the new war on the poor.

Berkeley CA: University of California Press; 2003. 13. Backman G, Hunt P, Khosla R, et al. Health systems and the right to health: an assess-

ment of 194 countries. Lancet. 2008;372:2047-2085. 14. Paim J, Travassos C, Almeida C, Bahia L, Macinko 1. The Brazilian health system:

history, advances, and challenges. Lancet. 2011 ;377: 1778-1797. 15. Sagan A, Panteli D, Borkowski W, et al. Poland: health system review. Health Systems

in Transition. Copenhagen: WHO European Observatory on Health Systems and Policies; 2011.

16. Spiegelhalter DJ, Gore SM, Fitzpatrick R, Fletcher AE, Jones DR, Cox DR. Quality of life measurements in health care. III: resource allocation. BMJ. 1992;305: 1205-1209.

17. United Nations Committee on Economic, Social and Cultural Rights. General Comment 14: The right to the highest attainable standard of health (EiC 1212000/4). Geneva: CESCR; 2000.

18. World health statistics 2012. Geneva: WHO; 2012. 19. Taylor AL, Hwenda L, Larsen BI, Daulaire N. Stemming the brain drain-a WHO

global code of practice on international recruitment of health personnel. N Engl J Med. 2011;365:2348-2351.

20. Adams CP, Brantner W. Spending on new drug development. Health Econ. 2010;19: 130-141.

21. Higgins MJ, Graham SJH. Balancing innovation and access: patent challenges tip the scales. Science. 2009;326:370--371.

22. 't Hoen E, Berger J, Calmy A, Moon S. Driving a decade of change: HlV / AIDS, patents and access to medicines for all. J Int AIDS Soc. 2011;14:15.

23. World Trade Organization (Doha WTO Ministerial 2001). Declaration on the TRIPS agreement and public health (WTIMIN(Ol)IDECI2); 2001.

24. Medecins Sans Frontieres. Fighting neglect: finding ways to manage and control visceral leishmaniasis, human African trypanosomiasis and Chagas disease. Geneva: MSF; 2012.

25. Frew SE, Liu VY, Singer PA. A business plan to help the 'global South' it its fight against neglected diseases. Health Aff. 2009;28: 1760-1773.

26. WHO model list of essential medicines (17th list). Geneva: WHO; 2011. 27. van den Ham R, Bero L, Laing R. Selection of essential medicines. In: The world

medicines report 20ll. Geneva: WHO; 2011. 28. The pharmaceutical industry and global health: facts and figures. Geneva: International

Federation of Pharmaceutical Manufacturers & Associations (IFPMA); 2011. 29. Lu Y, Hernandez P, Abegunde D, Edejer T. Medicine expenditures. In: The world

medicines report 20ll. Geneva: WHO; 2011. 30. Bill & Melinda Gates Foundation. Global health strategy overview. Seattle WA: Gates

Foundation; 2010. 31. Frost LJ, Reich MR. Access: how do good health technologies get to poor people in

poor countries? Cambridge MA: Harvard Center for Population and Development Studies; 2008.

32. Gliek PH. The human right to water. Water Policy. 1998;1:487-503.

References 359

33. Howard G, Bartram J. Domestic water quantity, service level and health. Geneva: WHO; 2003.

34. Bleumel EB. The implications of formulating a human right to water. Ecology Law Q. 2004;31 :957-1006.

35. Nickson A, Vargas C. The limitations of water regulation: the failure of the Cochabamba concession in Bolivia. Bull Latin American Res. 2002;21 :99-120.

36. Morgan B. Water: frontier markets and cosmopolitan activism. Soundings J Politics Nature. 2004;28:10-24.

37. Budds J, McGranahan G. Are the debates on water privatization missing the point? Experiences from Africa, Asia and Latin America. Environment Urbanization. 2003;15:87-113.

38. Hundley N Jr. Water and the West: the Colorado River Compact and the politics of water in the American West. Los Angeles: University of California Press; 2009.

39. Glennon R. Water scarcity, marketing, and privatization. Texas Law Rev. 2005;83:1873-1902.

40. The Sphere Project. Humanitarian charter and minimum standards in humanitarian response, 3rd edition. Rugby, UK: Practical Action Publishing; 2011.

41. Quarantelli EL. Just as a disaster is not simply a big accident, so a catastrophe is not just a big disaster. JAm Soc Professional Emerg Planners. 1996; 3: 68-71.

42. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature-a functional impact approach: the PICE system. Acad Emerg Med. 1996;3:723-727.

43. Thompson AK, Faith K, Gibson JL, Upshur REG. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006;7:12.

44. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over past decade. Lancet. 2004;364: 1801-1813.

45. Kalshoven F, Zegveld L. Constraints on the waging of war, 4th edition. Cambridge, UK: Cambridge University Press; 2011.

46. Kivlahan C, Ewigman N. Rape as a weapon of war in modern conflicts. BMf. 201O;340:c3270.

47. Young H, Borrel A, Holland D, Salama P. Public nutrition in complex emergencies. Lancet. 2004;364: 1899-1909.

48. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health. 1997;18:283-312.

49. UNHCR global report 2011. Geneva: UNHCR; 2011. 50. Spiegel PB, Checchi F, Colombo S, Paile E. Health-care needs of people affected by

conflict: future trends and changing frameworks. Lancet. 2010;375:341-345. 51. Global overview 2011: people internally displaced by conflict and violence. Geneva:

Internal Displacement Monitoring Centre, Norwegian Refugee Council; 2012. 52. Bmn C. Reterritorializing the relationship between people and place in refugee studies.

Geografiska Annaler: Series B, Human Geography. 2001;83: 15-25. 53. MacQueen G, Santa-Barbara J. Peace building through health initiatives. BMf.

2000;321 :293-296. 54. Brown VJ. BattleScars: global conflicts and environmental health. Environ Health

Perspect.2004;112:A994-AlOO3. 55. Landmine monitor 2011. International Campaign to Ban Landmines; 2011. 56. Machel G.lmpact of armed conflict on children (repmi A/51/306). New York: United

Nations; 1996.

360 CHAPTER 14 HEALTH, HUMAN RIGHTS, AND HUMANITARIAN AID

57. Spiegel PB. Differences in world responses to natural disasters and complex emergen- cies. lAMA. 2005;293:1915-1918.

58. Jobe K. Disaster relief in post-earthquake Haiti: unintended consequences of humanitar- ian volunteerism. Travel Med Infect Dis. 2011;9:1-5.

59. Sarcevic A, Palen L, White J, Starbird K, Bagdouri M, Anderson K. "Beacons of hope" in decentralized coordination: learning from on-the-ground medical twitterers during the 2010 Haiti earthquake. Proceedings of the ACM 2012 conference on Computer Supported Cooperative Work; 2012 Feb 11-15; Seattle WA. New York: ACM; 2012. p.47-56.

60. VanRooyen M, Leaning J. After the tsunami-facing the public health challenges. N Engl 1 Med. 2005;352:435-438.

61. Stumpenhorst M, Stumpenhorst R, Razum o. The UN OCHA cluster approach: gaps between theory and practice. 1 Public Health. 2011;19:587-592.

61. Krin CS, Giannou C, Seppelt 1M, Walker S, Mattox KL, Wigle RL, Crippen D. Appropriate response to humanitarian crises. BMl. 201O;340:c562.

63. National Incidence Management System. Washington DC: U.S. Department of Homeland Security; 2008.

64. McLoughlin D. A framework for integrated emergency management. Public Admin Rev. 1985;45(special issue): 165-172.

15.1 GLOBAL HEALTH

Global health has become an incredibly dynamic field. The 20th century was marked by unprecedented progress in medical science. New antibiotics were discovered along with a host of dmgs for treating noncommunicable diseases (NCDs) like heart disease and cancer. Life-saving vaccines were created. Oral contraceptives transformed family planning, and assisted reproductive technologies reduced the burden of infertility. New diagnostic tools, such as electrocardiographs, CT scans, and MRls, increased the quality of medical care. So did new therapies, like dialysis for disease, insulin for diabetes, and contact lenses for vision impairments. Modern surgical techniques made joint replacements, open heart surgery, and organ transplants routine in some parts of the world.

The 20th century was also characterized by a massive intensification of health disparities. While the global rich now have access to an array of healthcare innovations that would have been nearly unimaginable 100 years ago, the global poor continue to succumb to the same diseases that have been major killers for centuries, like hunger and measles and tuberculosis (TB). Richer countries have gone through demographic transitions, epidemiologic transitions, and nutrition transitions. Poorer countries are experiencing an increasing burden from diseases of affluence, while many of their residents

361

362 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

continue to die because they do not have access to food, hygiene, sanitation, basic health care, or other life essentials.

Yet despite these major differences in the health profiles of populations around the world, the 20th century also brought significant reminders of the common global threats to health. In particular, the emergence of HIV, virulent new strains of influenza, and drug-resistant pathogens prompted truly global research and practice efforts. Global research collaborations and global health partnerships have never been more important.

The goals of global public health in the 21st century are to continue to create innovative solutions to public health problems; to increase access to health, healthcare services, and health technologies around the world; and to expand global communication and action about shared health concerns. The first decade provides evidence that these aims can be accomplished, as progress has already been made on many fronts (Table 15-1).1

15.2 MILLENNIUM DEVELOPMENT GOALS

One of chief contributors to the global health successes to date in the 21st century is the Millennium Development Goals (MDGs) that were adopted by the United Nations (UN) in 2000 and have been endorsed by nearly 200 countries from across the globe. The MDGs set out eight major goals for significantly reducing global poverty by 2015 (Table 15-2).2 Most of these goals have direct links to health-eradicating extreme poverty and hunger (goal 1); reducing child mortality (goal 4); improving mater- nal health (goal 5); combatting HIV/AIDS, malaria, and other diseases (goal 6); and ensuring environmental sustainability (goal 7)-and all relate to creating an environment in which everyone has the tools to access health. Each UN member nation has committed to working toward these goals, so the MDGs have provided a blueprint for national-level priority setting, for bilateral and multilateral aid, and for World Bank and International Monetary Fund funding. Many nongovernmental organizations (NGOs) and international partnerships have also used the MDGs to guide their work.

Eighteen targets provide benchmarks for progress toward achieving the MDGs. Many of these are also directly health related. For example, some of the targets are to halve the proportion of people who suffer from hunger (target IC), to reduce by two-thirds the under-5 mortality rate (target4A), to reduce by three-quarters the maternal mortality ratio (target SA), to achieve universal access to reproductive health (target 5B), to begin to reverse the

15.2 Millennium Development Goals 363

Tab!e 15·~1 Top 10 global public health achievements in the first decade of the 21st century (2001-2010), as listed by the U.S. Centers for Disease Control and Prevention (CDC)

Reductions in child The number of children who die each year has mortality been reduced by more than 2 million

2 Vaccine-preventable An estimated 2.5 million deaths were prevented diseases

3 Access to safe water and About 800 million people gained access to sanitation an improved drinking water source and about

570 million gained access to improved sanitation

4 Malaria prevention and Malaria deaths have been reduced by about control 200,000 per year

5 Prevention and control of The number of new infections and the number HIV/AIOS of deaths each year have both been reduced

6 Tuberculosis control The case detection rate and successful treat- ment rate have increased

7 Control of neglected The transmission rates for Guinea worm and tropical diseases onchocerciasis (river blindness) are much lower

8 Tobacco control Most of the world's countries are participating in tobacco control efforts

9 Increased awareness and Many countries have lowered their annual response for improving number of traffic-related deaths global road safety

10 Improved preparedness Global health surveillance and response and response to global networks are being developed health threats

Source: Information from Global Public Health Achievements Team, CDC. Ten great public health achievements: worldwide, 2001-2010. Morb Mali Wkly Rep. 2011 ;60:814-818.

spread of HIV/AIDS (target 6A), to achieve universal access to treatment for HIV/AIDS for all those who need it (target 6B), to begin to reverse the incidence of malaria and other major diseases (target 6C), to halve the proportion of the popUlation without sustainable access to safe drinking water and sanitation (target 7C), and to provide access to affordable essen- tial drugs in developing countries, in cooperation with pharmaceutical companies (target 8E).

364 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

Table 15-2 Millennium Development Goals.

Eradicate extreme poverty and hunger

2 Achieve universal primary education

3 Promote gender equality and empower women

4 Reduce child mortality

5 Improve maternal health

6 Combat HIV/AIDS, malaria, and other diseases

7 Ensure environmental sustainability

8 Develop a global partnership for development

Source: United Nations. Millennium Development Goals. http://www.un.org /millenniumgoals/.

There are also 48 specific indicators that are used to assess whether the targets are being reached. These include measures of the preva- lence of underweight children in their first 5 years of life (indicator 1.8), the proportion of 1-year-old children immunized against measles (indicator 4.3), the proportion of births attended by skilled health per- sonnel (indicator 5.2), the contraceptive prevalence rate (indicator 5.3), the proportion of 15- to 24-year-olds with knowledge about HIV/AIDS (indicator 6.3), the proportion of TB cases detected and cured under directly observed therapy (DOTS) (indicator 6.10), and the proportion of the urban population living in slums (indicator 7.10). All the UN agencies are now collecting data from member states on the indicators relevant to their areas of work and are implementing programs that will support reaching the targets. 2

One of the main reasons the MDGs have been so influential is that they provide a clear strategy for evaluation. Progress on each of the 48 indica- tors is collected from each participating country on an annual basis so the status of each target can be monitored and countries can determine how much progress they have made toward reaching their goals (Table 15-3).3 The assessment data allow donors to determine whether programs are making good use of their resources and are on track toward achieving the desired outcomes. While some concerns have been raised about how well the MDGs promote equity, sustainability, local ownership of priorities, and holistic development (rather than relatively narrow, single-sector "silos" offocus), the general consensus is that the MDGs have provided a helpful framework for global cooperation toward international development. 4

Table 15-3 MDG progress for selected countries, circa 2010.

MDGGoal South Korea Brazil China India Kenya Sierra Leone

Achieved Achieved On track Possible Off track Possible

2 Achieved Achieved Oro track Possible On track On track '-v-. ~

3 Possible Achieved Possible Possible Possible On track §;

4 Achieved On track Possible Off track Possible Possible "---(\:) ;::: 5 Achieved On track 0" track Possible Possible Possible

;::: !2'

6 Achieved Achieved (Unknown) (Unknown) Possible On track ~ ti (\:)

7 (Unknown) On track (Unknown) (Unknown) Possible Off track ~ (\:) "-

8 (Unknown) On track (Unknown) (Unknown) (Unknown) (Unknown) ~ ~ (\:)

Source: Data from MDG Monitor country profiles 2012. New York: UN; 2012. ;::: ,...,. c;J \:) \:l 1:;""

W 0\ VI

366 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

15.3 CURRENT PRIORITIES

A variety of governments, international NGOs, and global health partnerships have created lists of various types of global health priorities for the coming years. For example, Table 15-4 lists the top 10 priorities from the Disease Control Priorities Project, sponsored by the Fogarty International Center of the U.S. National Institutes of Health and col- laborators such as the World Bank, the World Health Organization, and the Population Reference Bureau. In addition to the focus on infectious disease prevention and control (2, 4, 5), improved nutrition (3), and maternal and child health (1), this "top 10" list also emphasizes that every country in the world needs to begin preparing to provide health care (9, 10) to a large number of people with chronic, noncommunicable conditions (6, 7, 8).5

The Grand Challenges in Global Health list from the Bill & Melinda Gates Foundation takes a different approach, emphasizing the need for new scientific technologies (Table 15-5).6 The Grand Challenges initiative was launched in 2003 and focused on the creation of new and improved vaccines, vector control methods, and therapies, in part- nership with agencies such as the Foundation for the (U.S.) National Institutes of Health, the Wellcome Trust, and the Canadian Institutes of Health Research.

Table 15-4 Top 10 global health priorities from the Disease Control Priorities Project.

Ensure healthier mothers and children.

2 Stop the AIDS pandemic.

3 Promote good nutrition.

4 Stem the tide of tuberculosis.

5 Control malaria.

6 Reduce the toll from cardiovascular disease.

7 Combat tobacco use.

8 Reduce fatal and disabling injuries.

9 Ensure equal access to quality health care.

10 Forge strong, integrated, effective health systems.

Source: Information from Investing in global health: 'best buys' and priorities for action in developing countries. Disease Control Priorities Project; 2006.

153 Current Priorities 367

Table 15-5 Grand Challenges in Global Health.

Improve childhood vaccines Create effective single-dose vaccines

2 Prepare vaccines that do not require refrigeration

3 Develop needle-free vaccine delivery systems

Create new vaccines 4 Devise testing systems for new vaccines

5 Design antigens for protective immunity

6 Learn about immunological responses

Control insects that transmit 7 Develop genetic strategy to control agents of disease insects

8 Develop chemical strategy to control insects

Improve nutrition to promote 9 Create a nutrient-rich staple plant health species

Improve drug treatment of 10 Find drugs and delivery systems to limit infectious diseases drug resistance

Cure latent and chronic 11 Create therapies that can cure latent infection infection

12 Create immunological methods to cure latent infection

Measure health status 13 Develop technologies to assess accurately and economically population health in developing countries 14 Develop versatile diagnostic tools

Source: Information from Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA Grand challenge in global health. Science. 2003;302:398-399.

An international collaborative group exploring national and global responsibilities for health has proposed four key questions for global health that must be answered to move the field forward 7

Some lists designed to promote a set of health priorities in one country apply more globally, such as the list from the U.S. Centers for Disease Control and Prevention (CDC) shown in Tah!e 15~.8 Every country would benefit from attention to healthy living across the lifespan, improvements in the healthcare system, and the judicious adoption of new technologies.

368 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

Table 15-6 Four defining questions for global health.

What are the services and goods guaranteed to every person under the human right to health?

2 What responsibilities do states have for the health of their own populations?

3 What duties do states owe to people beyond their borders in securing the right to health?

4 What kind of global governance for health is needed to ensure that all states live up to their mutual responsibilities?

Source: Information from Gostin LO, Friedman EA, Ooms G, et al. The Joint Action and Learning Initiative; towards a global agreement on national and global responsibilities for health. PLoS Med. 2011 ;8:e1 001 031.

Table 15-7 Top 10 public health priorities in the United States, as listed by the U.S. CDC.

Institute a rational healthcare system (balance equity, cost, and quality)

2 Eliminate health disparities

3 Focus on children's emotional and intellectual development

4 Achieve a longer "healthspan" (healthy aging)

5 Integrate physical activity and healthy eating into daily lives

6 Clean up and protect the environment

7 Prepare to respond to emerging infectious diseases

8 Recognize and address the contributions of mental health to overall health and well-being

9 Reduce the toll of violence in society

10 Use new scientific knowledge and technological advances wisely

Source: Information from Koplan Jp, Fleming DW. Current and future public health challenges. JAMA. 2000;284: 1696-1698.

And some lists focus on just one category of disease but emphasize tools that would address a variety of health concerns, such as the NCD challenges list written by contributors from more than 50 countries and published in Nature, one of the leading science research journals (Table 15-8).9

Together, these lists provide insight into the common health priorities of nations and populations around the world-issues related to the major causes of disease, disability, and premature death; the socioeconomic and

15.3 Current Priorities 369

Table 15~8 Top 20 challenges for noncommunicable diseases (NCDs).

Raise public 1 Raise the political priority of NCDs awareness 2 Promote healthy lifestyle and consumption choices

3 Foster widespread, sustained, and accurate media coverage

Enhance 4 Address the impact of government spending and economic, taxation on health legal, and 5 Implement policies to discourage consumption of environmental alcohol, tobacco, and unhealthy foods policies

6 Address the impacts of poor health on economic productivity

Modify risk 7 Deploy measures proven to reduce tobacco use factors 8 Increase the availability and consumption of

healthy food

9 Promote lifelong physical activity

10 Better understand the environmental and cultural factors that change behavior

Engage 11 Make business a key partner in promoting health and business and preventing disease community 12 Develop and monitor codes of responsible conduct with

industries

13 Empower community resources

Mitigate health 14 Address how poverty increases risk factors impacts of 15 Address the links between the built environment, poverty and urbanization, and NCDs urbanization

Reorient health 16 Allocate health systems resources based on the burden systems of disease

17 Move health practice toward prevention

18 Increase the skills of professionals who prevent, treat, and manage NCDs

19 Integrate screening and prevention within health delivery

20 Increase access to medications to prevent complications of NCDs

Source: Information from Daar AS, Singer PA, Persad DL, et al. Grand challenges in chronic non-communicable diseases. Nature. 2007;450:494-496.

370 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

environmental factors that influence health; the funding and management of health systems; and the development and accessibility of new health technologies.

15,4 THE PRICE OF GLOBAL HEALTH

Many public health intervention packages would increase the quality of life of millions of people at a relatively low cost per person. For example:

• A package of road safety interventions-enforcement of speed lim- its, drunk driving laws, seatbelt use in cars, and helmet use by all motorcyclists and child bicyclists-could cost considerably less than a dollar per person per year in Africa and Southeast Asia. lO

• An integrated pharmacology package for treating neglected tropical diseases (NTDs )-albendazole or mebendazole for intestinal worms (ascariasis, trichuriasis, and hookworm), praziquantel for schisto- somiasis, ivermectin or diethylcarbamazine (DEC) for lymphatic filariasis and onchocerciasis, and azithromycin for trachoma-could cost less than $1 per person per year in sub-Saharan AfricaY

• An NCD "best buy" package suggested by the World Health Organization-with interventions for reducing tobacco use and harm- ful alcohol use, promoting physical activity and a healthy diet (that reduces sodium intake to lower the risk of hypertension and replaces trans fats with polyunsaturated fats to help reduce blood cholesterol levels), preventing cervical cancer through screening and removal of lesions, providing multidrug ("polypill") therapy to people at risk of a heart attack or stroke, and providing aspirin to people hav- ing an acute heart attack-could cost about $1 to $3 per adult per year in low- and middle-income countries, a tiny fraction of the costs of NCDs to the healthcare system if the prevention package is not implemented. 12

• An extra $2 per person per year in low- and middle-income countries could provide a package of antenatal and obstetric care that would prevent a substantial portion of stillbirths, neonatal deaths, and mater- nal deaths. 13

• A mental health package for treatment of depression, bipolar disorder, schizophrenia, and alcoholism with antidepressant, mood stabilizing, and antipsychotic medications and psychosocial therapy could cost only a few dollars per adult each year in low- and middle-income countries. 14

15.4 The Price of Global Health 371

However, all of these interventions together add up to a lot of money, especially for low-income countries where the total amount spent on health per person per year is significantly less than $100. For example, the Roll Back Malaria partnership needs about $6 billion annually in order to make progress on the Global Malaria Action Plan (GMAP), 15 the Global Plan to Stop TB requires nearly $10 billion each year,16 increasing access to clean drinking water and sanitation costs more than $20 billion annually,17 and providing modern contraception and maternal and new- born health care to all who would like these services but are not currently able to access them would require about $25 billion a year. 18 Together, trillions of dollars each year would be required to implement global health strategies for all of the various causes of disease, disability, and death in every region of the world. Thus, difficult decisions have to be made about how to allocate limited resources. Cost-effectiveness analysis, consider- ations of sustainability, and evaluations of the costs of doing nothing can provide support for making sound decisions about how to prioritize the distribution of funds.

15A.A

The goal of is to be sure that the funds being used for a public health initiative are at achieving the planned outcomes and are making use of financial and other resources. A variety of "best buys" in global health have been identi- fied, including a top 10 list from the Disease Control Priorities Project

5 The most cost-effective global health interventions tend to be relatively inexpensive, easily distributed to lots of people, and targeted toward children and young adults (so that they can avert many potential years of life lost to long-term disability or premature death). A child can be fully immunized for about $20 (best buy #1) and an inte- grated management of childhood illnesses (lMCl) package of vitamin A and zinc supplementation plus management of pneumonia, malaria, and diarrhea, including provision of oral rehydration therapy, costs less than $5 per child per year in sub-Saharan Africa (best buy #2).19 Hygiene promotion for the prevention of diarrheal diseases, deworming medications to reduce the burden from soil-transmitted helminths in endemic areas, first-aid training for emergency care, intermittent preven- tive treatment of malaria in pregnant women (IPTp) in endemic areas, and insecticide-treated bednets (ITNs) for malaria prevention are also

372 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

Table 15-9 Top 10 "best buys" in global health from the Disease Control Priorities Project.

Target Action

1 Child health Vaccinate children against major childhood killers, including measles, polio, tetanus, whooping cough, and diphtheria

2 Child health Monitor children's health to prevent or, if necessary, treat childhood pneumonia, diarrhea, and malaria

3 Tobacco use Tax tobacco products to increase consumers' costs by at least one-third to curb smoking and reduce the prevalence of cardiovascular disease, cancer, and respiratory disease

4 HIVIAIDS Attack the spread of HIV through a coordinated approach that includes: promoting 100% condom use among populations at high risk; treating other sexually transmitted infections; providing antiretroviral medications, especially for pregnant women; and offering voluntary HIV counseling and testing

5 Maternal and child Give children and pregnant women essential health nutrients, including vitamin A, iron, and iodine, to

prevent maternal anemia, infant deaths, and long- term health problems

6 Malaria Provide insecticide-treated bed nets in malaria- endemic areas to drastically reduce malaria

7 Injury prevention Enforce traffic regulations and install speed bumps at dangerous intersections to reduce traffic-related injuries

8 T8 Treat T8 patients with short-course chemotherapy to cure infected people and prevent new infections

9 Child health Teach mothers and train birth attendants to keep newborns warm and clean to reduce illness and death

10 Cardiovascular Promote use of aspirin and other inexpensive drugs disease to treat and prevent heart attack and stroke

Source: Information from Investing in global health: 'best buys' and priorities for action in developing countries. Disease Control Priorities Project; 2006.

15.4 The Price Global Health 373

highly cost-effective. 19 High-tech solutions, like coronary artery bypass surgery for treatment of ischemic heart disease, tend to be among the least cost-effective interventions. 19 In general, prevention is much less expensive than treatment.

Cost-effectiveness evaluations focus on how well an intervention con- tributes to achieving a goal. The goal may be something specific and mea- surable, such as reducing the incidence of malaria or increasing the number of people taking medications for HIV. Or the goal may be something less tangible and harder to quantify, such as reducing the risk ofbioterrorism or promoting new trade agreements via bilateral aid that helps communities address the conditions that foment violence or markets. No mat- ter what the goal is, the systematic collection of information about an ongoing project (monitoring) and the determination of whether the project is on track to achieve its objectives (evaluation), is an essential part of keeping in-progress interventions on track If the M&E process reveals that a project or program is not fulfilling its mandate, adjustments can be made to increase the impact of the inter- vention. Cost-effectiveness is critical for maximizing the outcomes of the resources put into global health activities.

aims to provide for current human needs without compromising the ability of future generations to meet their needs. Sustainable health programs aim to generate long-term health benefits that endure even after specific projects end. A program that depletes natural resources and promotes overconsumption is not sustainable, just as a program that is fully dependent on outside donors and does not involve recipients in planning, decision making, and evaluation is not sustainable. Ideally, global health programs should foster capacity building and encourage the self-sufficiency of participating communities, such as by facilitating the integration of successful externally funded healthcare programs into the routine services offered by internally funded national healthcare systems. 20 New NCD initiatives around the world that increase taxes on tobacco and other unhealthy products to support prevention and management of chronic diseases are examples of how health projects can be financially sustainable as well as socially and environmentally sustainable. 21

374 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

15.4.C Costs of Inaction

When considering the cost of solutions to global health crises, it can be helpful to compare the cost of action to the cost of inaction. Consider the economic costs of lost human life and lost productivity due to just a few common causes of disease and disability. Malaria-endemic countries have significantly reduced economic growth rates due to premature deaths, medical expenses, lost worker productivity, and other costs. 22 Nearly $400 billion is spent on treating diabetes and complications of diabetes worldwide each year.23 The per-person cost of excessive alcohol drinking in terms of lost productivity, direct healthcare expenses, law enforcement, and other costs is more than 1 % of the gross domestic product (GDP) in high- and middle-income countries, at a cost of several hundred dollars per capita.24 Knowing the high costs of these preventable conditions makes it possible to see how spending money can, in the long term, save money. For example, the money spent on controlling malaria would likely signifi- cantly expand national economies in currently endemic areas, preventing type 2 diabetes through lifestyle changes and other measures would save huge costs to healthcare systems, and curbing excessive drinking would significantly reduce the burden of injuries and NCDs in addition to enhanc- ing economies.

15.5 BEYOND COST-EFFECTIVENESS

A focus on cost-effectiveness is not by itself sufficient for making decisions about health priorities and health funding. One limitation is that cost-benefit analyses tend to promote interventions that have already proven to be successful (in at least one population in one part of the world) and to downplay innovations that have not yet proven to achieve reliable results. New inventions are necessary for moving global health forward, even though creative ideas can be "risky" uses of resources. For example, vaccine programs, if successful, are extremely cost-effective, but there is a chance of failure, and the up-front cost of research and development is extremely high. Still, it is important for some funding agencies and research organizations to be willing to risk failure so that new technologies and innovative approaches to global health problems can be developed.

15.5 Beyond Cost-Effectiveness 375

Another shortcoming of cost-effectiveness analysis is that it often requires the analysts to make judgments about what a healthy life is worth. The calculations may require an estimate of how much it costs a disabled person to be unable to work, or an approximation of how much a year of life is worth for a 70-year-old compared to a 7-year-old. While these sorts of estimates may be helpful at the population planning level, they break down at the individual level. Estimates of lost wages do not capture the burden of lost self-sufficiency that may accompany a disability. Few families would put a price tag on grandpa and deem his year of life to be worth less than that of his grandchild.

Global health statistics, budget details, and progress reports tend to hide individual human beings behind numbers, reducing real people to nameless, faceless masses. A few million children dying from preventable diseases like diarrhea and malaria. A few million people with treatable mental health issues going untreated. A few million young adults with HIV infection gaining access to life-saving antiretroviral medications. A few million households gaining access to a reliable source of clean drinking water. But statistics cannot capture the profound grief experienced by families who lose a child, just as they cannot fully express how life-changing a new water well can be.

It is important that people involved in local health and global health never lose sight of health being about real people-people who merely want the means to be healthy enough to be able to support themselves and their families, and who hope they will be fortunate enough to see their children and grandchildren grow up. Staying attuned to the human side of global health sometimes means acting out of simple compassion or a sense of solidarity with other human beings, whether those people live next door or on the other side of the planet. 25 Global health in the 21st century has the tools and technology to discover groundbreak- ing new ways to promote health and prevent disease and disability, to significantly improve health standards and reduce health disparities, to tackle the problems associated with extreme poverty, and to bring together people from across the world as equals to address our common health challenges. If we choose to prioritize global health in the coming decades-both because it makes economic sense to do so and because it makes "human" sense to foster everyone's health and well-being-we have the opportunity to make unparalleled improvements in the lives of billions of people.

376 CHAPTER 15 GLOBAL HEALTH PROGRESS AND PRIORITIES

15.6 DISCUSSION QUESTIONS

1. What achievements would you include in a list of the top 10 global health successes of the 20th century (the 1900s)?

2. What are five specific items you would like to include in a "top 10" list of current global health priorities? Before making your list, consider the diversity of health issues (such as infectious diseases, nutrition, NCDs, mental health, and injuries) affecting various populations across the lifespan and across the globe that could be included in the list.

3. For each of the five current priorities you identified, what is one rela- tively cost-effective method for addressing the concern?

4. For each of the five current priorities you identified, what is one orga- nization that is currently working to address the concern? What are the approaches each of these organizations is using to achieve its global health goals?

5. If you had $1 million to spend on improving global health, what would you do with the money?

6. If you had $25 to contribute toward improving global health, what would you do with the money?

7. How should decisions about how to spend global health funds be made? How should health concerns be prioritized? How should interventions be selected?

8. What items do you hope will be included in a list of the top 10 global health successes of the 21st century (the 2000s)?

REFERENCES

1. Global Public Health Achievements Team, CDC. Ten great public health achievements: worldwide, 2001-2010. Morb Mort Wkly Rep. 2011;60:814-818.

2. The Millennium Development Goals report 2011. New York: United Nations; 2011. 3. MDG Monitor country profiles 2012. New York: UN; 2012. 4. Waage J, Banerji R, Campbell 0, et al. The Millennium Development Goals: a cross-

sectoral analysis and principles for goal setting after 2015. Lancet. 2010;376:991-1023. 5. Investing in global health: 'best buys' and priorities for action in developing countries.

Disease Control Priorities Project; 2006. 6. Varmus H, Klausner R, Zerhouni E, Acharya T, Daar AS, Singer PA. Grand challenge

in global health. Science. 2003;302:398-399. 7. Gostin LO, Friedman EA, Ooms G, et al. The Joint Action and Learning Initiative;

towards a global agreement on national and global responsibilities for health. PLoS Med.2011;8:e1001031.

References 377

8. Koplan JP, Fleming DW. Current and future public health challenges. lAMA. 2000;284: 1696-1698.

9. Daar AS, Singer PA, Persad DL, et al. Grand challenges in chronic non-communicable diseases. Nature. 2007;450:494-496.

10. Chisholm D, Naci H, Hyder AA, Tran NT, Peden M. Cost effectiveness of strategies to combat road traffic injuries in sub-Saharan Africa and South East Asia: mathematical modeling study. BMf. 2012;344:e612.

11. Hotez PJ, Molyneux DH, Fenwick A, et aL Control of neglected tropical diseases. New Engl J Med. 2007;357:1018-1027.

12. Scaling up action against noncommunicable diseases: how much will it cost? Geneva: World Health Organization; 2011.

13. Pattinson R, Kerber K, Buchmann E, et aL; The Lancet Stillbirths Series steering com- mittee. Stillbirths: how can health systems deliver for mothers and babies? Lancet. 2011;377:1610-1623.

14. Chisholm D, Lund C, Saxena S. Cost of scaling up mental healthcare in low- and middle-income countries. Br J Psychiatry. 2007;191:528-535.

15. Roll Back Malaria annual report 2011. Geneva: WHO; 201 I. 16. The global plan to stop TB 2011-2015. Geneva: Stop TB Partnership; 2011. 17. UN-Water Global Analysis and Assessment of Sanitation and Drinking-Water. GLAAS

2012 Report. Geneva: WHO; 2012. 18. Singh S, Darroch JE, Ashford LS, Vlassoff M. Adding it up: the costs and benefits of

investing in family planning and maternal and newborn health. New York: UNFPAI Guttmacher Institute; 2009.

19. Laxminarayan R, Mills AJ, Breman JG, et al. Advancement of global health: key mes- sages from the Disease Control Priorities Project. Lancet. 2006;367: 1193-1208.

20. Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998;13:87-108.

21. Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011;377:1438-1447.

22. Sachs J, Malaney P. The economic and social burden of malaria. Nature. 2002;415:680-685.

23. Zhang P, Zhang X, Brown J, et al. Global healthcare expenditure on diabetes for 2010 and 2030. Diabetes Res Clin Pract. 201O;87:293-30l.

24. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattanonon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol use disorders. Lancet. 2009;373:2223-2233.

25. Benatar SR, Daar AS, Singer PA. Global health ethics: the rationale for mutual caring. Int Affairs. 2003;79: 107-138.

ABCs of AIDS prevention, 229-230 AbOliion, 124

cause of morbidity/mortality, 110, 117-118

population planning, 127, 132 sex selection, 115, 132

Abstinence, 122-124,205 Abstract, 38, 42 Abt Associates Inc., 305 Acanthamebiasis, 211 Access to health care (see Healthcare

access) Acculturation, 351 Accuracy, 60-61 Acid rain, 328 Active immunity, 214 Active surveillance, 216 Activities of daily living (ADLs), 150 Acupuncture, 92 Acute (definition), 194 Acute respiratory infection (ARI) (see

Pneumonia) Advocacy, 294

and access to medication, 277, 343 and technology, 345-346

Aedes aegypti mosquitoes, 202, 213, 327 African sleeping sickness, 116, 195,

201,203 control efforts, 205, 244

Aga Khan Foundation, 290 Age adjustment, 21, 25 Agent (of infection), 188

Agent-host-environment, 218 Aging

and disabilities, 148-154 and life expectancy, 23 and NCDs, 148-154 and vital statistics,S, 8, 137-139

Aging index, 158 Agriculture

and child labor, 105 and community development, 287, 294 and environmental change, 237, 325,327 and food security, 262-263, 354 and policy, 296-297, 301 and pollution, 180, 311-312 and water, 171, 347

AIDS (Acquired Immunodeficiency Syndrome) (see mY/AIDS)

AIDS orphans, 103, 228 Airborne transmission, 194-195,200 Air pollution

indoor, 164-165, 178-179,312 and lung disease, 28, 148, 166, 178,

231,326 outdoor, 164-165, 182,312,328-329

Alcohol use, 33, 111 consumption rates, 27 and policy, 369-370, 374 as a risk factor for NCDs, 26-28,

142-143, 165 by young adults, 110-111

Aldehydes, 178 Allele, 33

379

380 INDEX

Allergies, 31, 329 Alma-Ata Conference, 101 Alpha (a) error, 58 Alternative energy sources, 178, 329-330 Alveoli, 94-96, 147 Alzheimer's disease, 25, 33, 116,

153-154,293 Amebic dysentery, 198 American Cancer Society, 38, 293-294 American Heart Association, 293-294 American Jewish World Service, 303 American Red Cross, 290, 293, 305 American sleeping sickness, 201, 203

control efforts, 205, 244 and environmental change, 326

Amino acids, 191,250 Amnesty International, 294 Amoeba, 190 Amoebiasis, 197-198 Analytic studies, 44-52 Anemia, 266

and children, 237-238, 266 and hookworm, 208, 268 and iron deficiency, 116,265-267 and malaria, 96, 237-238 and nutrition, 255-256, 266-267 and pregnancy, 121,238,266 and sickle cell, 78

Anencephaly, 254 Angina, 141 Angiogenesis, 142 Anopheles mosquitoes, 237, 202 Anorexia nervosa, 35, 321 Antenatal (prenatal) care, 93, 103, 120,370 Anthrax, 211, 322-323 Anthropometry, 257-258 Anthroponosis, 195 Antibiotics, 189, 215-216

and pneumonia, 96 and pregnancy, 93, 121 and resistance, 81, 215-216, 235, 367 and STIs, 53, 204 and TB, 81 and viruses, 189

Antibodies, 194,250 and breastrnilk, 97-99

Antigenic drift, 243

Antigenic shift, 243 Antigens, 242-243, 367 Antihelminthic drugs

and children, 269 and mass drug administration, 208, 215 and pregnancy, 93

Antimicrobial resistance, 215-216 MRSA,316 TB, 81, 235

Antioxidants, 254-255 Antiretroviral drugs (ARVs), 225

access to, 228, 230-231, 343 pregnancy, 229, 230

Antiviral drugs, 189-190,215 mV,225

Anxiety disorders, 25, 34, 35 Apicomplexa, 190 Apoptosis, 142 Appropriate technology, 168 Arbovirus, 202 Arm circumference, 257 Arsenic, 181,324

arsenicosis, 182-183 arsenopyrites, 183

Artemisia (artemisinin), 240 Artemisinin-based combination therapy

(ACT), 240 Arthritis (osteoarthritis), 116, 153 Arthropods, 202 Arusha Conference (Second African

, Population Conference), 132 Asbestos, 166, 180 Ascariasis, 205-208, 370 Aspergillosis (Aspergillus), 199 Association (statistical), 10, 11,45 Asthma, 147

and environment, 179, 182, 329 Astroviruses,319 Atherosclerosis, 140-141, 252 Athlete's foot, 191,211 Attributable risk (AR, AR%), 49 AusAID,300 Autism, 35 Autoimmune disorders, 31,116 Autonomy, 53 Avian influenza, 243, 310 Azithromycin, 370

Babesiosis (Babesia), 201 Bacilli, 188 Back pain, 179, 268 Bacteria, 188-189

and antibiotics, 215-216 and diarrheal infections, 91, 196-198,319 and drug resistance, 215-216, 316 and NTDs, 208-209 and respiratory infections, 96, 200 and STIs, 204 and vectorbome infections, 200-202

Balantidiasis, 197 Bartonellosis, 200-201 BCG (Bacillus Calmette-Guerin), 235-236 Beauty, 321 Bednets (see Insecticide-treated bednets) Behavioral risk factors, 10 Behavior disorders, 35 Beijing Declaration on Women, 105 Beneficence, 52-53 Benzene, 142, 181,324 Beriberi (thiamine deficiency), 255, 263 Best buys in global health, 370-372 Beta-carotene (see Vitamins) Beta (/3) error, 58 Bhopal, India, 180-181 Bias, 59-60 Bifidus factor, 99 Big Mac Index, 73 Bilateral aid, 285-287, 289 Bilharzia (see Schistosomiasis) Bill & Melinda Gates Foundation, 244,

289,345,366 Binge-purge cycles, 321 Bioavailability, 267 Biodiversity, 328 Biomass, 178, 312 Biostatistics, 16

attributable risk, 49-51 Chi-squared test, 58 confidence interval, 47, 49, 57, 58 correlation, 54-55 efficacy, 51-52 odds ratio, 45-48 power, 58 p-value, 58-59 rate ratio, 48-51

risk difference, 49-51 risk ratio, 48-51 sampling, 57

Index 381

screening tests, 154-155 t-test,58

Bioterrorism,322-325 Biotin, 255 Bipolar disorder, 35, 110, 370 Bird flu (see Influenza) Birth asphyxia, 88-92 Birth control pills (see Oral contraceptives) Birth defects, 92-93, 180, 254, 293 Birth rate, 21

and health transitions, 5-7, 314 Birth spacing, 93,121-122 Birth trauma, 88 Bitot's spots, 264 Black death (see Plague) Black (Simulium) flies, 202, 203 Bladder cancer, 116, 194 Blastomycosis, 199 Blindness, 105-106, 148-149

diabetes, 148 infectious causes, 203, 210 vitamin A deficiency, 264-265

Blood blood disorders, 32 bloodmeal, 203, 237 blood pressure (see Hypertension) and oxygenation, 94-96 transmission by, 194, 221 and water, 252

Body image, 321 Body mass index (BMI), 257, 272 Borehole, 167 Botulism, 189, 197, 323 Bovine spongiforrn encephalopathy (BSE),

191,212 Brain drain, 340 Brazil (featured throughout book) Breakbone fever (see Dengue fever) Breast cancer, 111, 143-146, 156,293 Breastfeeding,97-100

and continued feeding for diarrhea, 94-95,103

early breastfeeding, 99 exclusive breastfeeding, 99

382 INDEX

Breastfeeding (continued) and global health initiatives, lOl-lO4 and HIV, 195,221,229-230 and neonatal health, 93 recommended duration, 99 and undernutrition, 97-100, 268

Breastmilk, 97-99, 214, 229 substitutes for, 99-lO0 and mv, 99, 221, 229

Breech births, 93 Broad Street pump, 164 Bronchitis, 96, 147 Brucellosis, 197-198,323 Bubonic plague, 200-201 Bulimia nervosa, 35, 321 Burden of disease, 25

by age group, 8 and aging, 137-139 and children, 87-88 classification, 29 DALY, 25-26 dual burden, 7 and epidemiologic transitions, 5-8, 25 and health systems resources, 369 infections, 30, 188 injuries, 34-36,113-114 measurement, 21-37 mental health, 33-34, 109-111 NCDs, 31-33,140-149 nutrition, 260, 270 by sex, 116

Burns, 34-37, 110-111, 113-114, 116, 178 Buruli ulcer, 208, 210-211 Businesses and health, 290, 305, 369

and environmental health, 179, 182 pharmaceutical companies, 244, 290,

340-343 and public-private partnerships, 214,

301-302 USAID contractors, 305

Cadmium, 180-181 Cairo Conference on Population and

Development, 127 Calcium, 256, 263 Campaign for Access to Essential

Medicines, 343

Campylobacteriosis, 91,197-198,319 Canadian Institutes of Health Research

(CIHR), 296, 366 Canadian International Development

Agency (CIDA), 300 Cancer, 142-147, 165 (see also specific

types of cancer) incident rates, 143-145 mortality rates, 140, 143-146 risk factors, 26-28, 142-143, 165, 194 survival rates, 143, 146

Candidiasis, 191,211 Candles, 176 Capsid, 189 Carbohydrates, 249-250 Carbon dioxide

and breathing, 94-96,147,252 and environment, 182

Carbon monoxide, 178, 182 Carcinogens, 180 Carcinoma, 142 Cardiovascular disease, 116, 140-142

and environmental change, 329 prevalence, 111, 140-141 prevention, 142 risk factors, 12, 26-28, 257 in young adults, 109-111

Careers in global health, 15-16,244,294-295 Carotene (see Vitamins) Carpal tunnel syndrome, 179 Carrier (of infection), 195,241 Carrying capacity, 129 Carson, Rachel, 183 Carter Center, 244, 292 Case-control study, 44-48 Case definition, 25 Case detection rate, 235, 363 Case fatality rate, 194 Case series, 44 Case study, 44 Cataracts, 116, 148-149, 153,329 Catastrophe, 129, 348 Catholic Relief Services, 292, 303 Causal web, 13-14 Causation, 10-13 CDC (U.S. Centers for Disease Control

and Prevention), 37, 244, 296, 368

CD4 cells, 221-225 Cellular respiration, 249 Cerebral malaria, 96, 237-238, 241 Cerebral palsy, 105, 259 Cerebrovascular accident, 141-142 Cervical cancer, 142-146

and HPV, 28,142-143,156,194,370 Cesarean section, 120 Chagas disease, 201, 203, 205, 244, 326 Chancre, 204 Charcoal, 176, 178 Chemonics International Inc., 305 Chernobyl, Ukraine, 180 Chickenpox (varicella), 98, 211 Chikungunya fever, 201 Child abuse, 36,103-105,115 Childbirth (see Pregnancy) Child growth, 257-258

and growth standards, 257-258 and micronutrients, 254-256, 265-267 and monitoring, 102 and undernutrition, 258-261

Child health, 87-106 infectious disease, 90-98 injury, 91, 103 mortality, 8, 87-90, 92 neonatal conditions, 87-90, 92 nutrition, 94, 97-101 programs, 101-106

Child labor, 104-105 Child soldiers, 105 Child spacing, 93,121-122 Child sponsorship, 290-291 China (featured throughout book)

population planning policies, 132-133 and SARS, 217, 310

Chiropracty,82 Chi-squared (X2) test, 58 Chlamydia, 116, 204 Chloride, 256 Chloroquine, 240 Cholera, 98,195-198,323-324

outbreaks, 4, 163-164, 198,317 Cholesterol, 26-28, 252, 370

and heart disease, 12, 12, 156 Chromium, 256 Chromosomes, 31-33,115

Index 383

Chronic (definition), 194 Chronic conditions (see Noncommunicable

conditions) Chronic Obstructive Pulmonary Disease

(COPD), 111, 116, 140, 147-148 and environment, 178-179, 182 risk factors, 148

Church Wodd Service, 303 Ciliates, 190 Circumcision

female (see Female genital mutilation) male circumcision and HIV, 230

Cirrhosis, 32, 116 Cleft lip/cleft palate, 105 Climate and disasters, 348 Climate and health, 152, 165,318 Climate change (see Environmental health)

Clinical trial, 51 Clonorchiasis, 208 Cluster

humanitarian response, 354 outbreaks, 216

Coal, 176-178, 182 Coca-colonization, 320 Cocci, 188 Coccidioidomycosis, 199 Cochabamba, Bolivia, 346-347 Codex Alimentarius, 320 Cohort, 47 Cohort study, 47-51 Colds (viral), 194, 198-199

and antibiotic misuse, 96, 216 Collective violence, 34-36 Colorectal cancer (colon cancer), 143-146 Colostrum, 99 Commercial sex workers (CSWs),

115,228 Communicable disease (see Infectious

diseases) Communication technologies, 68,

178-179,309-310 and emergencies, 330, 354-356

Community-based participatory research (CBPR),41

Community development, 291, 294 Community health (see Public health) Compassion International, 291-292

384 INDEX

Complementary / Alternative Medicine (CAM), 82-83

Complementary feeding, 99, 103,268 and diarrhea, 95

Complementary protein, 250 Complete protein, 250 Complex humanitarian emergencies,

349-352 Conditional survival, 23 Condoms

pregnancy prevention, 122-123,213 STIIHIV prevention, 124, 194,205,213,

228-230, 372 Confidence interval, 95% (95% CI),

45-47,49-50,57-58 Conflict (see Violence) Confounding, 60 Contact tracing, 217 Continued feeding, 94-95 Contraception, 122-124, 127-128,

132-133,371 Control

disease prevention and control, 196, 210,213-214,217,244

in research, 44-45, 51, 60 vector control, 164, 183-184, 195,

204, 367 Convention on the Rights of the Child, 104 COPD (see Chronic Obstructive

Pulmonary Disease) Copper, 256 Copyright, 342 Corneal ulceration, 264 Coronary artery disease, 141 Corporate social responsibility, 290 Correlation, 54-55 Correlational study, 54-55 Corruption, 303 Cost-effectiveness

global health initiatives, 61-62, 371-375 health systems, 29, 339 nutritional interventions, 265 screening/secondary prevention, 156

Cretinism, 256, 265 Creutzfeldt-Jakob Disease (CJD), 191,212 Crimean-Congo hemorrhagic fever, 201 Crisis, 347-348

Crop rotation, 262-263 Cross-sectional survey, 42-43 Crowding

and infection, 67, 231, 327 and injuries, 35-36 and prisons, 80-81 and urbanization, 312-315

Cryptococcosis, 199,223 Cryptosporidiosis, 190, 197-198,319,

323-324 Culture, 82-83

of dependency, 304 and gender roles, 117,321 and nutrition, 100-101

Cutaneous leishmaniasis, 203 Cut-off point, 155-156 Cutting, 36 Cycle of displacement, 79, 351 Cycle of infection, 196 Cyclosporiasis, 197 Cystic fibrosis, 33, 93

DALY (disability-adjusted life year), 25-26,29-30,371

and disability weights, 25-26, 375 and mental health, 25,109-110

Dams, 317, 330, 348 and schistosomiais, 206, 327

DDT (dichloro-diphenyl-trichyloroethane), 183-184

Deafness, 105, 149 Death rate (see Mortality rate) Debt

and debt forgiveness, 289 and health insurance, 279-280 and repayment, 289

Deer flies (Chrysops), 201 Deer tick (Ixodes scapularis), 201 Default rate, 235 Definitive host, 196 Deforestation, 178,317,325,327 Dehydration, 90-91, 95, 252 Delusions, 34-35, 110 Dementia, Ill, 153-154 Demographic transition, 5-7, 127,361 Demography, 21 Denatured proteins, 191

Dengue fever, 195,201-202,213,326-327 Dental health, 32, 254-256, 279

dentistry, 2-3, 341 Dependency ratio, 158 Depression, 25, 109-112, 116,370 Dermatomycoses, 191,211 Descriptive research, 43 Desertification, 171-172,328 Developmental disorders, 33-35, 105-106 Development organizations (see

Community development) Deworming, 93,121,176,208,215,371 DFID (U.K. Department for International

Development), 300 Diabetes, 148-149,374

and body size, 257 and pregnancy, 121 prevalence, 27, 111, 116, 140 and screening, 156

Diaper rash, 191 Diaphragm, 122-123 Diarrhea, 195,326

and children, 90-95, 104 and environment, 91 and the 6 Fs, 174

Diet (see Nutrition) Dioxins, 180, 324 Diphtheria, 98, 199 Diphyllobothriasis, 208 Direct transmission, 194 Disability, 15,66,149-153

disability-adjusted life year (see DALY) and environment, 152-153 and injury, 37, 120 measurement, 22, 25-26 and mental health, 34, 109-110 and poverty, 152

Disaccharide, 250 Disasters, 247-249, 347-349, 352-355

bioterrorism, 322-325 complex humanitarian emergencies,

304-305,349-350 coordinated response, 352-353 human-generated disasters, 347-353 immediate needs, 294, 347-347, 351,

352-355 natural disasters, 347-348, 352-355

preparedness, 356-357 refugees/lOPs, 350-351

Disease (definition), 193

Index 385

Disease Control Priorities Project, 366, 371-372

Diseases of affluence, 5, 320 Diseases of Workers, 179 Disparities

in health, 7-8, 66-67, 78, 296-297 Distributive justice, S3 DNA (deoxyribonucleic acid), 33 Doctors (see Medicine) Doctors Without Borders, 292, 343 Domains of activity and participation,

151-152 Domestic violence (see Interpersonal

violence) Dominant genes, 33 Donor countries, 285-289, 299-301 Donor-driven aid, 303 Dose-response effect, 11 DOTS (directly observed therapy,

short-course), 234-236 DOTS Plus, 235

Double-blind studies, 51 Doubling time (population growth), 128 Down Syndrome (Trisomy 21),33 Dracunculiasis (see Guinea worm disease) Drought, 262, 318, 328, 248 Drowning, 34-36, 110, 114, 116,326 Drug abuse, 26, 33, 80, 116,301

and HIV, 221-222, 228, 230 Drug companies (see Pharmaceutical

companies) Drug resistance (see Antimicrobial

resistance) Drug sales (see Pharmaceutical sales) Drug trials, 52 Dual burden (see Burden of disease) Dung, 176

Early breastfeeding, 99 Eating disorders, 35, 321 Eating practices, 101,270-272,

320-321 Ebola, 211, 316-317, 322-323 Echinococcosis, 209

386 INDEX

Eclampsia, 117, 121 E. coli, 91, 189, 196-197,319,323-324 Ecological fallacy, 55 Ecological footprint, 129-130 Ecological study, 54-55 Economic indicators, 72-77 Ecotoxicology, 180 Ectoparasite, 190 Edema, 259 Education and educational level, 65-67,

70-71 Effectiveness, 371

efficacy, 51-52 efficiency, 371

Effect modification, 60 Ehrlichiosis,201 Elderly (see Aging)

elder abuse, 36 elderly support ratio, 158

Electricity, 176-179,310-311 Electrolytes, 91, 94, 254 Elephantiasis, 203 Elimination, 217 Emergency, 347-348

emergency management, 356 4 Rs, 356

Emerging infectious diseases, 316-318, 323-324,368

Emphysema, 147, 164 Employee benefits, 69 Employment, 65-66, 69-70 Encephalitis, 97,210-212, 323 Endemic, 216 Endoparasite, 190 Endotoxin, 189 Energy, 176-179,355 Enrichment of food, 267, 320 Enterobiasis, 209 Environmental health, 16, 163-184,

325-330 environmental change, 318, 325-330 history, 163-164 indoor air quality, 176-179 industrial/occupational health, 164-166,

179-181 laws, regulations, and policies, 179-180,

182,214,301,329-330

outdoor air pollution, 182 sanitation, 172-177 urban environments, 310-315 water, 167-172,346-347

EPI (Expanded Programme on Immunization), 101-102

Epidemic, 129, 216 Epidemiologic study designs, 42-56 Epidemiologic transition, 5, 7-9, 361 Epidemiology, 16, 41 Epilepsy, 10, 25, 33, 344 Epstein-Barr virus, 212 Equilibrium theory of health, 82 Eradication, 217-218, 244, 298 Ergonomics, 165 Escherichia coli, 91,189,196-197,319,

323-324 Esophageal cancer, 116, 143-146 Essential amino acids, 250 Essential medications (see Healthcare

access) Essential support functions (ESFs), 355 Ethics (see Health and human rights;

Research ethics) ethics committee (see Institutional

Review Board) Ethnicity, 66, 77-79 Etiology, 10 Eukaryote, 190 Evidence-based medicine (EBM), 61 Excess risk, 49-50 Exclusive breastfeeding, 95, 99, 268 Exotoxin, 189 Expanded Programme on Immunization

(EPI),101-102 Expatriates ("expats"), 303 Experimental studies, 42, 50-52 External validity, 60-61 Extinction, 217, 328

Faith-based organizations (FBOs), 303 Falls, 12,34-36, 114, 116 Family Health Internatipnal

(FHI 360), 305 Family planning, 101-102, 122-124,

132-133, 350 pill, 122-123

Famine, 129,262-263,330 F AO (Food and Agriculture Organization

of the United Nations), 299, 354 Farr, William, 163-164 Fascioliasis, 209 Fasciolopsiasis, 209 Fats, 9, 250-253 Fat-soluble vitamins, 250, 259, 264, 267 Fatty acids, 250-252 Fecal-oral transmission, 195-196 Feed the Children, 292 Female education, 70-71,101-102,

125-127 Female genital mutilation (FGM), 105,

115, 121 Female literacy, 70-71, 125-127 Fertility, 124--125

and aging, 137, 156-159 and health transitions, 5-7 and policy, 130-133

Fertility rate, 125-127, 131 Fertility transition, 6-7 Fiber, 250 Filariasis (see Lymphatic filariasis) Filters (see Water filters) Fistula (see Obstetric fistula) Flagellates, 190 Flatworms, 190,208 Fleas, 200-202, 205, 218 . Flies, 172-174,200-203 Floods, 312, 317-318,328-329,

348, 352 Flour, 267 Flukes, 190,208 Fluoride, 254-256

fluorosis, 254-256 Flying toilet, 174 Fogarty International Center, 366 Folate, 93, 121,254-255,266-268 Folic acid (see Folate) Fomite, 195 Food and Agriculture Organization of the

United Nations (FAO), 299, 354 Food desert, 260-261 Food for the Poor, 292 Food production, 101-102, 129,260-263,

320,350

Index 387

Food safety, 198,213-214,319-320, 323-324

foodborne transmission, 195-198, 319-320

home practices for, 320 International Food Standards, 320

Food security, 260-263, 311, 347, 354 Ford Foundation, 289 Forecasting, 56 Fortification of food, 267, 320 Foundations, 289-290 Fracture, 12, 255, 263 Framework Convention on Climate

Change, 182 Framework Convention on Tobacco

Control, 298 Framingham Heart Study, 48 Free radicals, 254 Freshwater resources, 171-173,328,

346-347 Fructose, 249-250 Fuel, 68, 166, 176-179,311,329-330

and emergencies, 347, 351 Functional impairment, 150 Functional literacy, 70 Funda<;ao Oswaldo Cruz (Fiocruz), 296 Fungi, 191, 199-200,211,223

Gametocytes, 237 Gang violence, 36 Garbage (see Waste management) Gates Foundation (see Bill & Melinda

Gates Foundation) G8 nations, 289 Gender, 66,116-117

roles, 114-115, 117 General Agreement on Tariffs and Trade

(GATT),342 General Agreement on Trade in Services

(GATS),342 General Assembly of the United Nations,

104,298 Generalizability, 60-61 Generic drugs, 342-343 Genes, 16,31-33,77-78,115-116,270 Genetically modified organisms (GMOs),

320, 365

388 INDEX

Genetic mutations, 33,142-143,180 Geneva Convention, 304 Genocide, 78, 348 Genotype, 33 Geology, 165, 183 German measles (see Rubella) Germ theory, 163 Giardiasis, 197-198,319 Gini Index, 75-76 Glanders, 323 Glaucoma, 116, 148, 156 Global Alliance for Improved Nutrition

(GAIN), 302 Global Alliance for Vaccines and

Immunizations (GAVI), 244, 289,302

Global environmental change, 325-330 Global Fund to Fight AIDS Malaria and

Tuberculosis (GFATM), 230-231, 289,302,343

Global health, 4 aging, 137-140, 156-159 child health, 87-106 environmental health, 163-184,

325-330 funding, 277-293 implementers, 294-305 history, 4 humanitarian disasters, 347-356 human rights, 335-347 infectious diseases, 187-218,221-244,

316-318,322-325 injuries, 113-115 mental health, 109-113 metrics, 19-39 NCDs,140-156 nutrition, 249-272, 319-321 priorities, 361-375 reproductive health, 117-133 transitions, 4-9 urbanization, 310-315 vulnerable populations, 77-83

Global Health Initiative (U.S.), 301 Globalization, 309-310

and nutrition, 319-321, 326 Global Malaria Action Plan, 371 Global Plan to Stop TB, 236, 302, 371

Global warming (see Global environmental change)

Glucose, 27, 148,249-250 GOBI Initiative, 101-102

GOBIIFFF,101-102 Goiter, 256, 265 Golden rice, 265 Gonorrhea, 116, 196,204,215 Governmental responsibilities for health,

335-336 access to health, 338-340 human rights, 335-338 public health, 284, 296-298 reproductive health, 132-133 surveillance, 216

Government-sponsored health care systems, 278-283

Grameen Foundation, 294 Gram-negative bacteria, 188 Gram-positive bacteria, 188 Grand Challenges in Global Health,

366-367 Grant, 287 Gravidity, 124-125 Gross domestic product (GDP), 72-73 Gross national income (GNJ), 72-73 Gross national product (GNP), 73 Group A Strep (Streptococcus), 199-200 Growth monitoring, 101-102,257-258 Growth standards, 257-258 Guinea worm disease, 205-206, 209, 218,

244,363

HAART (Highly Active Anti-Retroviral Therapy), 225

and access to essential medications, 228, 230-231,343

and pregnancy, 229-230 Haemophilus injluenzae type B (Hib),

96-98, 199-200 Haiti earthquake (2010), 290, 348, 352-353 Hallucinations, 109-11 0 Hand-washing (see Hygiene) Hansen's Disease, 192,208-211,244 Hantavirus, 199,317,323-324,327

hantavirus pulmonary syndrome (HPS),317

HDL (high-density lipoprotein) cholesterol, 252

Health, 1-2 in all policies, 296-297 behaviors, 16,78, 165,210-213 beliefs, 82-83 charities, 291-293 disparities, 7-8, 66-67, 78, 296-297 economics, 16,277-293 education, 16,210-213

Health Belief Model, 210-211 Health for All by 2000, 101 Health Services Administration, 16,

277-280 information systems, 37, 277 technologies, 344-346 transitions, 4-9

Health and human rights, 335-347 access to essential medications, 277,

324-325,340-344 access to healthcare services and

technology, 338-346 access to water, 346-347 child rights, 104-106 and disasters, 349 international hnmanitarian laws,

349-350 mental health rights, 111-112 prisoner rights, 80-81 standard of health, 335-336, 338 Universal Declaration of Human Rights,

335-337 Healthcare access, 311, 338-346

to essential medications, 277, 324-325, 340-344

and maternal health, 119-122 and mental health, 111-112 and poverty, 68-69, 339 to services and technology, 338-346 to water, 346-347

Healthcare costs, 277-282 drug costs, 296, 340-345 personal costs, 280-282 public costs, 283-293

Health inequalities, 66-67, 77, 296-297

Health inequities, 77

Index 389

Health insurance, 278-280, 283, 296 and access to health services, 338 and employment, 69

Health policy, 3, 16, 152 environmental policies, 182,214,

263,369 evidence-based policy, 61-62

Health in All Policies, 296-297 population planning, 127, 130-133, 158 public health interventions, 10, 12-13,

213,272,338 Healthspan, 368 Health systems, 2, 28-29, 277-280, 339

and global health priorities, 366, 369 Healthy life expectancy, 22 Hearing impairment, 149 Heart attack (myocardial infarction),

140-141 Heart disease (see Cardiovascular disease) Heat waves, 328-329 Height-for-age, 257, 259 Helicobacter pylori, 194, 197-198 Helminths, 190

and environmental change, 326-327 and NTDs, 205-209, 244 vectorborne, 203

Hemagglutinin, 242-243 Heme iron, 266 Hemoglobin, 250, 265-266 Hemolytic uremic syndrome, 196-198 Hemophilia, 32-33 Hemorrhage

hemorrhagic fevers, 201, 210-211, 316-317,322-323

maternal hemorrhage, 110-111, 117-118,121

strokes, 141 Hepatitis A virus, 98, 193, 197,319 Hepatitis B virus, 98, 116,204-205 Hepatitis C virus, 116, 189, 194,211 Herbal remedies, 82 Herd immunity, 214-215 Herpes, 190, 204-205 Hib (see Haemophilus influenzae type B) RIPC Initiative, 289 Hippocrates, 163 Histoplasmosis, 191, 199

390 INDEX

HIV/AIDS Africa, 225-228 AIDS (Acquired Immunodeficiency

Syndrome), 222 children, 90-91, 228-229 drugs, 225, 228, 343 Global Health Initiatives, 230-231 HIV-l,221-222 HIV-2 (Human Immunodeficiency

Virus type 2), 222 incidence/prevalence, 222, 225-229, 317 opportunistic infections, 222-224 orphans, 228 prevention, 229-230 risk factors, 228-229 stages, 223-225 TB coinfection, 223-224, 231-234 transmission, 221-222 treatment, 190,225,228,230,343 women, 228-229 young adults, 109-111

Holistic approaches to health, 82-83, 101-104,364

Homeopathic remedies, 82-83 HINI influenza, 242-243 Hookworm, 196,205-209,267,370 Horizontal public health initiatives,

101-102 Hospital-acquired infections (HAIs),

316,318 Host (of parasites), 190, 196,208 Household size (see Crowding) Housing, 66-68, 312 HPV (human papillomavirus), 28, 98,

142-143,194,204-205 Human Development Index (HDI), 75-77 Human Development Report (HDR), 38 Human Immunodeficiency Virus (see HN) Humanitarian aid (see various types of aid

agencies) disaster aid, 347-355

Human papillomavirus (HPV), 28, 98, 142-143,194,204-205

Human rights, 4, 335-340 (see also Health and human rights)

child rights, 104-106 civil and political rights, 336-337, 349

constitutional rights, 339 economic, social, and cultural rights,

336-337,349 and emergencies, 349 mental health rights, 111-112 prisoner rights, 80-81

Human Rights Watch, 294 Human trafficking, 79,115 Hunger (see Undernutrition) Huntington's Disease, 33 Hydatid cyst disease, 209 Hygiene, 26,150,164

and diarrheal disease, 13,91,176,198, 268,326,371

and disasters, 347, 354 facial hygiene and trachoma, 210 and poverty, 68 water access, 167-169,346

Hymenolepiasis, 209 Hyperglycemia, 26, 148 Hypertension (high blood pressure), 26,

141-142,254 and NCD mortality, 28 and pregnancy, 118, 121 and screening, 155 and stroke, 28, 141

Hypoglycemia, 148 Hypothermia, 93 Hypothyroidism, 265 Hypovolemic shock, 252 Hypoxia, 96

IA VI (International AIDS Vaccine Initiative), 230-231, 302

IBRD (International Bank for Reconstruction and Development), 287-288

ICRC (International Committee of the Red Cross), 304-305, 354

IDA (International Development Association), 288

Idiopathic, 10 Illness, 82 ILO (International Labor Organization),

105,179,299 IMCI (Integrated Management of

Childhood Illness), 101-104,371

IMF (International Monetary Fund), 287-289

Immigrants, 79 refugees, 350-351 rural-to-urban, 159, 166,312-314

Immune system, 31,192-194,214, 221-223

Immunization childhood recommendations, 97-98, 102 vaccine biology, 214-215 vaccine trials, 52

Immunoglobulin (Ig), 99, 214 Immunosuppression, 191, 318 Impairment, 150-153 Imported food, 319 Impulse control disorders, 34-35 Inactivity (see Physical inactivity) Incidence, 24

incidence rate, 24,48-50,216 Incident Command System (ICS), 355 Income (household), 65-67 Incubation period, 193 India (featured throughout book)

Indian Council of Medical Research (ICMR),296

Indian Health Service (IRS), 279 Indigenous peoples, 79 Indoor air pollution, 164-165, 178-179,312

and lung disease, 148, 166, 178,231,326 Indoor residual spraying (IRS), 184,

241-242 Induced abortion, 124 Industrial health, 165-166, 179

industrial accidents, 37, 180-181, 348 Inequalities (see Health inequalities) Inequities (see Health inequities) Infant, 87

global health initiatives, 101-104 infant mortality, 90-101

Infant formula, 99 Infection (definition), 193 Infectious diseases, 30,187-218

agents, 188-192 diarrheal infections, 90-95, 196-198 and environmental change, 329 HIY,221-231 incidence/prevalence, 29-31, 188

influenza, 242-243 malaria, 96, 236-242 NTDs, 205-210

Index 391

prevention and control, 210-218 respiratory infections, 94-96, 198-200 STIs, 204-205 transmission, 194-196 tuberculosis, 81, 231-236 vaccines, 97-98, 214-215 vectorbome infections, 200-204

Infectivity, 192 Infertility, 117, 133,204,361 Inflammation, 31 Influenza, 5,98, 194-195, 198-199,

242-243 Information bias, 60 Information sources, 37-39, 42-43 Informed consent, 53 Injecting drug use (IDU), 222-228 Injuries, 34-37,113-115

and children, 90-91,104-105 and disasters, 347-352 epidemiology, 7, 29-30, 110, 139 and occupation, 69, 165, 179

Insect-borne transmission (see Vectorborne transmission)

Insecticide, 195,203-204,214,238,325 DDT,183-184

Insecticide-treated bednets (ITNs), 93, 97, 103-104,241-242,371-372

Institute of Medicine, 317-318 Institutional Review Board (IRB), 51,

52-54,60,298 Instrumental Activities of Daily Living

(IADLs), 150 Insulin, 148 Insurance (see Health insurance) Integrated Management of Childhood

Illness (IMCI), 101-104,371 Intentional injury, 34-35, 114 Interferon, 205 Intergovernmental Panel on Climate

Change (IPCC), 328-329 Intermediate host, 196 Intermittent presumptive treatment (IPT),

93,241,371 Internally displaced person (lOP), 348, 351

392 INDEX

Internal validity, 60 International Agency for Research on

Cancer (IARC), 38 International AIDS Vaccine Initiative

(IA VI), 230-231, 302 International Bank for Reconstruction and

Development (IBRD), 287-288 International Centre for Settlement of

Investment Disputes (ICSID), 288 International Classification of Functioning

Disability and Health (ICF), 151 International Code of Marketing of

Breast-milk Substitutes, 100 International Committee of the Red Cross

(ICRC), 304-305, 354 International Court of Justice, 298-299 International development and cooperation

agencies, 299-301 International Development Association

(IDA), 288 International Finance Corporation (IFC), 288 International health (definition), 4 International Labor Organization (ILO),

105,179,299 International Monetary Fund (IMP),

287-289 International NGOs, 292, 302-304 International Organization for Migration

(roM), 354 Interpersonal violence, 34-36 Interventions

child health, 102 cost-effectiveness, 371-375 educationlliteracy interventions, 71 evidence-based interventions, 10, 61-62 mV/AIDS,230 intervention research studies, 50-52 malaria, 241 maternal mortality, 121 modifiable risk factors, 26 neonatal, 93 nutritional, 97, 268 prevention levels, 14 socioeconomic determinants of health,

65-67 tuberculosis, 236

Intrauterine device (IUD), 122-123

Invasive species, 325, 328 Iodine, 256, 265, 267

and pregnancy, 93, 372 Iodine deficiency disorders (IDD), 265 IRE (see Institutional Review Board) Iron, 254, 256, 265-267

iron deficiency anemia (IDA), 265-267 IDA and children, 103, 266-268, 372 IDA and pregnancy, 93, 116, 121,

266-267,372 Irrigation, 171

and infections 206, 237, 327 Ischemia, 141 Islamic Relief, 303 Isolation, 110, 195,200 IUD (intrauterine device), 122-123 Ivermectin, 370

Japan earthquake (2011), 290 Japanese encephalitis, 98, 201-202, 326 JICA (Japan International Cooperation

Agency), 300 Job security, 69 John Snow Inc., 305 J-shaped curve (population growth), 128

Kala azar (visceral leishmaniasis), 201, 203 Kangaroo mother care, 93 KAP (knowledge, attitudes, practices),

43,213 Kaposi's sarcoma, 223 Kenya (featured throughout book) Kenya Medical Research Institute

(KEMRI),296 Keratomalacia, 264 Kerosene lamps, 176 Kidney disease, 31,141,148,293 Kilimanjaro Programme of Action, 132 Kissing bugs, 201, 203 Klebsiella, 96, 199 Knock knees (see Rickets) Kuru, 212 Kwashiorkor, 259 Kyoto Protocol, 182

Lactobacillus bifidus, 99 Lactose, 91, 249

Landmines, 352-353 Lassa fever, 211, 323 "Late, long, few" policy in China, 132 Latent phase, 154, 193, 367

latent TB, 231 Latrine (see Toilet) LDL (low-density lipoprotein)

cholesterol, 252 Lead,26, 166, 180-181,324 Legionnaire's Disease, 199-200,316 Leishmaniasis, 116,201,203,205,244 Leprosy (Hansen's Disease), 192,

208-211,244 Leptospirosis, 211 Leukemia, 142, 179,293 Lice, 190,200-202,204-205,212 Life expectancy, 22-23

at birth, 22, 73-75 and health transitions, 4-5 healthy life expectancy, 22

Lifestyle diseases, 9 Lind, James, 179 Lipids, 250-253 Listeriosis, 197-198,319 Literacy, 65-67, 70-71, 75 Liver cancer, 143-146, 194 Loans, 287-289 Logistics, 294-295, 352-355 Loiasis, 201 Long-lasting insecticide-treated nets

(LUNs),241 Low birthweight (LBW), 93, 122, 238,

259-260 Lower respiratory infections (see

Pneumonia) Lung cancer, 111, 116, 143-146

risk factors, 28, 164-166, 178-179 Lupus, 31,116 Lyme Disease, 195,200-201,327 Lymphatic filariasis (LF), 116,201,

203, 326 control programs, 205, 244, 370

Machupo virus, 323 Macroeconomic indicators, 72-76 Macronutrients, 249-253 Macular degeneration, 148

Index 393

Mad cow disease, 191,212 Magnesium, 256 Malaria

anemia, 237-238 cerebral malaria, 237-238 children, 90-91, 96-97, 103-104 combination therapy, 240 drug resistance, 240 environment, 165,237-238,242,326 global health initiatives, 242 incidence/prevalence, 222, 238-240 Plasmodium, 236-237 pregnancy, 238 prevention, 183-184,240-242 risk factors, 237-238 transmission, 195,237 treatment, 240

Malaria Vaccine Initiative, 242 Malnutrition, 31

and environment, 326 overnutrition, 268-272 undernutrition, 97, 257-260, 263-268

Malta fever (see Brucellosis) Malthus, Thomas, 129 Malthusian catastrophes, 129-130 Mammography, 156 Manganese, 256 Mantoux test for TB, 235 Manual laborers, 69, 179 Marasmus, 259 Marburg virus, 211, 322-323 Marriage, 21, 105, 114-117, 125 Massage, 82 Mass drug administration (MDA),

208,215 Maternal and child health (MCH),

87-88 child health, 87-106 family planning, 122-128 maternal mortality, 31, 117-122

Maternal mortality (death), 31,117-122 Mathematical modeling, 56 McDonaldization, 320 MDGs (Millennium Development Goals),

362-365 MDR-TB (Multidrug-resistant TB), 81,

215,233,235

394 INDEX

Measles, 97,192,195-196,211 child mortality, 90-91 malnutrition, 102,259,264 vaccination,72,95,98,372

Mechanistic theory of health, 82 Mectizan, 290 Medecins Sans Frontieres (MSF),

292,343 Medicaid, 279 Medical research (see Research) Medical Research Council (MRC),

UK,296 Medicare, 279 Medicine, 2-3, 38, 82-83, 277, 341 Medicines for Malaria Venture

(MMV), 242, 302 Mefloquine (Lariam), 240 Meliodosis (Burkholderia

pseudomallei), 323 Memory loss (see Dementia) Meningitis, 87, 189,210-212 Meningococcus, 98,211 Mental health (see Neuropsychiatric

disorders) Mental retardation, 33, 35, 259 Mercury, 180-181,320,324 Meta-analysis, 42-45, 55-56 Metabolism, 255, 265 Metastasis, 142 Methicillin-resistant Staphylococcus

aureus (MRSA), 215, 316 Methyl isocyanate, 181 Miasma, 163-164 Microcredit programs, 294 Microfilariae, 203 Microloans, 294 Micronutrients, 249, 254-256, 263-268 Mid-upper arm circumference

(MUAC),257 Midwife, 120,341 Migraine headaches, 33,116,344 Migration 25,79

and conflict, 349-351 and famine, 262 and healthcare professionals, 340 rural-to-urban, 159, 166, 312-314

Millennium Challenge Corporation, 301

Millennium Development Goals (see MDGs) Minerals, 28, 31, 254-256

calcium, 256, 263 chloride, 256 chromium, 256 copper, 256 fluoride, 254-256 iodine, 256, 265 iron, 256, 265-267 magnesium, 256 manganese, 256 molybdenum, 256 phosphorus, 2556 potassium, 94, 254, 256 selenium, 256 sodium, 254, 256, 370 supplementation, 92-95, 121,254,

267-268,371 zinc,94-97,103,256,257

Miscarriage (spontaneous abortion), 124-125, 198

Mites, 190, 202 Mitigation, 356 MMWR (Morbidity and Mortality Weekly

Report),38 Modes of transmission, 194-196 Modifiable risk factors, 10, 14,26-28 Mold, 166, 191,329 Mole checks, 156 Molluscicides, 206 Molybdenum, 256 Monitoring and evaluation (M&E), 373 Mononucleosis, 212 Monounsaturated fatty acids, 252 Mood disorders, 34-35,109-112 Moralistic theory of health, 82 Morbidity (definition), 24 Mortality (definition), 24 Mortality rate, 21

and children, 87-88 and health transitions, 4-6 and socioeconomic status, 68 and young adults, 113, 117-119

Mosquitoes, 201-202 control, 183-184,213,325

Mosquito nets, 93, 97,103-104,241-242, 371-372

Mother-to-child transmission (MTCT), 93, 195,221,229-230

Mouth cancer, 116, 144 MRS A (Methicillin-resistant

Staphylococcus aureus), 215, 316 MSF (Medecins Sans Frontieres), 292, 343 Multidrug-resistant TB (MDR-TB), 81,

215,233,235 Multifactorial conditions, 12 Multilateral aid, 285-289 Multilateral Investment Guarantee Agency

288 Multiple sclerosis (MS), 12 Multivitamins (see Vitamins) Mumps, 98, 212 Mutations, 33, 142-143, 180 Mycobacterium tuberculosis (see

Tuberculosis) Mycobacterium ulcerans infection, 208,

210-211 Myocardial infarction, 141

Naegleriasis, 212 National Incident Management System

(NIMS),355 National Institutes of Health (U.S. NIH),

37,296 Natural disasters, 348-349, 352-355 Natural history of disease, 154, 192 NCDs (see Noncommunicable diseases) Necessary cause, 12 Negative predictive value (NPV), 155 Neglected tropical diseases (NTDs),

205-210,244,370 Nematodes, 190 Neonates, 87

neonatal health promotion, 90-93 neonatal mortality, 88-92

Neoplasms (see Cancer) Nestle, 100 Neural tube defects, 93, 254 Neuraminidase, 242-243 Neuropsychiatric disorders, 25, 29-30,

33-35,109-114,329 New World Syndrome, 320-321 NGOs (see Nongovernmental

organizations)

Niacin, 255, 263 Night blindness, 264

Index 395

NIH (U.S. National Institutes of Health), 37,296

Nipah virus, 199,323 Nitrogen, 188 Nitrogen oxide, 178 Noise, 149, 164-165, 179,312,325 Noncommunicable diseases (NCDs),

31-34, 137-153 and aging, 137, 140 cancer, 142-147 cardiovascular disease (CVD), 140-142 COPD,147-148 dementia, 153-154 diabetes, 149 disability, 150-153 incidence/prevalence, 29-30 prevention, 370 risk factors, 26-28 screening, 154-156 sensory impairment, 148-149 stroke, 141-142

Nonderogable right, 349 Nongovernmental organizations (NGOs),

302-304 Nonheme iron, 266-267 Nonmaleficence, 53 Norovims, 197-198,319 Nosocomial (hospital-acquired) infections,

316,318 Null results, 56 Nursing, 2-3, 82, 120, 341 Nutrition, 97-101, 249-272

child, 97-101, 257-260, 264-268 and environment, 262-263, 311, 329 macronutrients, 249-253 micronutrients, 254-256 , 263-268 overnutrition, 257, 268-272 undernutrition, 257-268

Nutrition transition, 5, 9, 321, 361

Obesity, 9, 257, 268-272, 321 as a risk factor for NCDs, 26-28,

]48, 165 Observational research, 42-51 Obstetric fistula, 120-121

396 INDEX

Obstructed labor, 117, 120-121 OCHA (UN Office for the Coordination of

Humanitarian Affairs), 354 Occupation, 65-66, 69-70

occupational health, 165-166, 179 Occupational therapy, 153 Odds, 45-46

odds ratio (OR), 45-47 OECD (Organisation for Economic

Co-operation and Development), 285-287

Official development assistance (ODA), 286-287

OHCHR (Office of the UN High Commissioner for Human Rights), 299,354

Oils, 250-252 Older adults (see Aging) Omega-3 fatty acids, 252 Onchocerciasis, 153,202-203,205,244,363

drug therapy, 215, 290, 370 One child policy in China, 132 One Health, 320 Open defecation, 95, 174-176, 308, 311 Opportunistic infections (OIs), 222-224, 230 Oral contraceptives, 122-123 Oral Rehydration Solution (ORS), 94-95,

101-104,268,371 Oral Rehydration Therapy (ORT), 94-95,

101-104,268,371 Organic food, 326 Organ transplantation, 318 Osteoarthritis (arthritis), 116, 153 Osteomalacia, 255, 263 Osteoporosis, 12, 149,263 Outbreaks, 38, 187,216-217

contact tracing, 217 diarrhealinfections, 163-164, 198,

319-320,350-351 emerging infectious diseases,

316-317,324 herd immunity, 214-215 influenza, 242-243 measurement, 24 quarantine, 217 respiratory infections, 200, 217, 310, 317 vectorborne infections, 203, 317

Outdoor air pollution, 164-165, 182,312, 328-329

and lung cancer, 28, 148, 166 Outhouse, 172 Out-of-pocket health payments,

278-283,338 Ovarian cancer, 144 Overhunting/overfishing, 352 Overnutrition, 9, 268-272 Overweight, 9, 26-28, 165,257,268-272 Ovulation, 122 Oxfam, 291 Oxygen

and anemia, 252, 265-266 and cardiovascular disease, 140-141 and malaria, 237-238 and respiratory disease, 94-96, 147

Ozone depletion, 328-329

Paid sex, 105, 115, 228 Palliative care, 15, 230 Pandemic,216,242-243,348

Pandemic Alert System, 243 Panic disorder, 35, 110, 135 Pantothenic acid, 255 Pap smear, 143, 156 Paragonimiasis, 209 Paralysis, 120, 153, 203, 212 Paramecium, 190 Parasite, 190-191 Paratyphoid fever, 197-198 Parity, 124-125 Parkinson's Disease, 10, 12,25,33, 149 Parrot fever (see Psittacosis) Particulate matter, 178, 182 Passive immunity, 214 Passive surveillance, 216 Pasteurization, 198,319 Patent, 342-343 PATH, 289, 292 Pathogenesis, 189 Pathogenicity, 193 PCBs (polychlorinated biphenyls),

180-181,324 Peace,298,335-336,352 Peace Corps, 285, 300 Pediculosis, 212

Peer review, 38, 60 Pellagra (niacin deficiency), 255, 263 Pelvic Inflammatory Disease (PID), 204 Penicillin, 53 Pension plans, 159 PEPFAR (U.S. President's Emergency

Plan for AIDS Relief), 230, 301, 343 Peptidoglycan, 188 Perinatal conditions, 31, 88-93 Periodic abstinence, 122-123 Persistent organic pollutants (POPs),

183-184 Person-Place-Time, 43 Person-to-person transmission, 194 Pertussis, 98, 199-200 Pesticides, 180, 320 Pharmaceutical companies

access to medication, 340-343 donation programs, 290 and infectious disease control

initiatives, 244 Pharmaceutical sales, 344-345 Phenotype, 3 Phosphorus, 256 Phthiriasis, 204 Physical impairment, 150-153 Physical inactivity, 26-28, 33, 165 Physical therapy, 2-3, 105, 153 PICE nomenclature, 349 Pinworm, 208-209 Pit latrine, 172-l7 4, 325 Placebo, 51 Plague, 4, 195,200-202,322-323,327 Planned Parenthood, 128 Planned urbanization, 310-312 Plasmodium, 202, 236-237 Play, 104 Pneumococcal pneumonia, 96-98,

199-200 Pneumocystis carinii pneumonia (PCP),

191,222-223 Pneumonia, 198-200

and children, 91, 94-96 and environment, 326 prevention, 200 and young adults, llO

Poisoning, 36,114,116, l79-180, 326-327

Index 397

Poland (featured throughout book) Policy (see Health policy) Polio, 98,212

global eradication initiative, 218, 244, 298, 304

Polycyclic aromatic hydrocarbons (PAHs),181

Polypill, 370 Polysaccharides, 250 Polyunsaturated fatty acids, 252, 370 Pontiac fever, 199-200,316 Pooled risk, 278-280 Population demographics

density, 129 growth, 128-130,314 pyramid,156-158

Population planning, 127-128, 130-133 Population Reference Bureau, 366 Portal of entry, 194,316 Positive predictive value (PPV), 155 Post-exposure prophylaxis (PEP), 194,

225, 324 Postpartum hemorrhage, 110-111,

1l7-118,121 Posttraumatic stress disorder (PTSD), 35,

116,351 Potassium, 91, 94, 254, 256 Pott, Percival, 179 Poverty line, 67 Power

social, 77, 114-115,228-229 statistical, 58

PPD test for TB, 235 Praziquantel, 206, 370 Precision, 61 Preeclampsia, 117, 121 PregnancY,31,117-122

contraception, 122-124 and HlY, 229-230, 372 and malaria, 237-238, 241 and nutrition, 254, 264, 266, 268, 372

Prenatal (antenatal) care, 93, 103, 120,370 Presbycusis, 149 President's Malaria Initiative (PMI), 301 Preterm (premature) birth, 90-93, 122, 198 Prevalence, 24-25

survey, 43-44

398 INDEX

Prevention, 13-15 (see specific prevention activities)

causal web, 13-14 levels, 14-15

Primary Health Care (PHC), 101-102 Primary prevention, 14-15 Primary research, 42 Primary sources, 38 Prion, 191-192,212 Prisoners, 80-81, 228

of war (POWs), 304-305 Private health insurance, 278-280, 283 Private voluntary organization (PVO),

302-304 Probability value, 58-59 Professional workers, 69, 179

in public health, 15-16,87,294-295 Program, 295 Progress-Plus model, 65-66 Project, 295 Prospective study (see Cohort study) Prostate cancer, 143-146, 156 Prosthetics, 26, 153 Protease inhibitors, 225 Proteins, 250-251

and child undernutrition, 97,101, 258-259

andprions,191-192 protein-energy malnutrition (PEM),

259-260 Protozoa, 190

and diarrheal infections, 198 and respiratory infections, 200 and STIs, 205 and vectorborne infections, 202-203

Psittacosis, 199-200,323 Psychiatry, 112,341

neuropsychiatric disorders, 25, 29-30, 33-35,109-114

Psychology, 312,336 Pterygium, 165 Publication bias, 56 Public health, 2-3

careers, 15-16 core disciplines, 16 goals, 8 laws and regulations, 3, 369

Public-private partnerships, 301-302 examples, 244, 343

PubMed,38,42 Pulmonary TB (see Tuberculosis) Purchasing power parity (PPP), 73

p-value (probability value), 58-59 Pyrethroid insecticide, 241 Pyridoxine, 255

Q fever (Coxiella bumetii), 199,323 Qi,82 Quality-adjusted life years (QALY s), 25 Quality of life (see Standard of living) Quarantine, 217 Questionnaire, 61

r,54 Rabies, 98,194-196,212 Race, 77-78 Radiation, 33, 37, 180,325,328-329,348 Radio (see Communication technologies) Radon, 166 Ramazzini, Bernadino, 179 Randomized controlled trial (RCT), 51 Rape, 114-115,350 Rate difference (RD), 49-50 Rate ratio (RR), 48-50 Readiness, 356 Reading global health reports, 37-39,

59-61 Recall bias, 60 Recessive genes, 33 Recovery rate, 193 Red blood cells (RBCs)

and anemia, 238, 265-266 and malaria, 96, 237 and nutrition, 254-256 and pneumonia, 94-96

Red Crescent (see Red Cross) Red Cross

ICRC, 304-305 national organizations, 290, 291, 293,

305,354 Re-emerging infectious diseases, 316 Reforestation, 327 Refrigeration, 13-14,68, 178,320,367 Refugee, 79, 299, 348, 350-351

Registered trademarks, 342 Rehabilitation, 15, 112, 153, 352 Relative risk (RR), 48-50 Reliability, 61 Relief, 294, 347, 351 Religion, 66, 77-79,82,336-337,350

FBOs, 291, 303 and population planning, 127

Repetitive motion injury, 165 Replacement population, 125-127 Representativeness, 44 Reproductive health, 117-128 Reproductive history, 124-125 Reproductive rights, 127-128 Research

ethics committee (see Institutional Review Board)

information sources, 38-39 study designs, 41-62 uses, 3, 25, 294, 296

Research ethics, 52-54 Reservoir, 195-196,317 Respect for persons, 53 Respiratory system, 94-96 Retinol (see Vitamins) Retirement, 159 Reverse transcriptase inhibitors, 225 Rheumatic fever, 200 Rheumatoid arthritis, 31,116 Rhinovirus, 194, 199 Riboflavin, 255, 263 Ricin, 323 Rickets, 255, 263 Rickettsia, 200 Rift Valley fever, 201 Rights of the girl-child, 105 Right to health (see Health and human

rights) Ringworm, 191,211 Risk difference (RD), 49-50 Risk factor, 10-12 (see specific types of

risk factors) common modifiable risk factors, 26-28 evidence-based public health, 62

Risk ratio (RR), 48-50 River blindness, 153, 202-205, 363

drug treatment, 215, 290, 370

Index 399

Road traffic injuries (see Traffic accidents) Rockefeller Foundation, 289 Rocky Mountain spotted fever, 200--202 Rodents, 166, 195,204,214,311-312,327 Roll Back Malaria, 242, 302, 371 Roman Catholic Church, 127 Rotary International, 244, 292, 304 Rotavirus, 91,197-198,318

vaccination, 95, 97-98 Roundworm, 190,206-208 Rubella (German measles), 98, 212 Rural health, 66, 68, 260, 310-312, 314

and utilities, 171, 174-176, 177 RUTF (ready-to-use therapeutic food), 259

Saccharide, 249-250 Safe motherhood programs, 121-122 Salmonellosis (Salmonella), 91,195,

197-198,319,323-324 Salt

and hypertention, 254, 370 and iodization, 265, 267 and ORS/ORT, 94 saltwater, 171

Sample size, 56-57 Sampling, 56-57 Sandflies, 201, 203 Sanitation, 172-177, 311 Sarcoma, 142 SARS (Severe Acute Respiratory

Syndrome), 217, 310 Saturated fatty acid, 252 Save the Children, 291-292, 354 Scabies, 190,212 Scarlet fever, 200 Scatterplot, 54 Schistosomiasis, 116, 194, 196,209,

267,370 and control initiatives, 205, 215, 244 and environment, 206, 326-327

Schizophrenia, 25, 34-35,109-111,370 Screening, 15, 154-156 Scrotal cancer, 179 Scurvy, 179,255,263 Secondary attack rate, 192 Secondary contacts, 217 Secondary prevention, 14-15, 154-156

400 INDEX

Secondary research, 42 Secondary sources, 38 Secondhand smoke, 164 Selection

bias, 59 biological process, 215-216

Selenium, 256 Self-inflicted injuries, 34-36,

110-111,114 Sen, Amartya, 262 Sensitivity, 154-156 Sentinel surveillance, 216 Septic tank, 172-174 SES (see Socioeconomic status) Severe acute malnutrition (SAM), 259-260 Sewage system, 172-174,311 Sex, 115-116

differences in health status, 116 sex-selective abortions, 115-132 sexual abuse, 104-106, 112, 114-115 sexual health, 117 sexually transmitted infections (STIs),

115-116,121,123-124,204-205, 221-231

sex workers, 115, 228 Shantytowns (see Unplanned urbanization) Shelter, 116,347,351,354 Shigellosis, 91,195,197-198,319,

323-324 Shingles, 211 Sickle cell anemia, 33, 78 Sickness, 82 Sickness funds, 278 Sierra Leone (featured throughout book) Silent Spring, 183 Silk Road, 309 Skilled workers, 69,179

skilled birth attendant, 118-122 Skin cancer, 142, 156, 165, 183,329 Slope (on a graph), 54-55 Slums (see Unplanned urbanization) Smallpox, 195,217,298,322-323 Snails, 196,206,214,327 (see also

Schistosomiasis) Snow, John, 164 Social capital, 66 Social determinants of health, 65-67

Social insurance systems, 278 Social security systems, 283, 296 Socioeconomic position (SEP), 65-72 Socioeconomic status (SES), 65-72 Sodium, 91, 254, 256, 370 Soil-transmitted helminth (STH), 206-209,

244,371 South Korea (featured throughout book) Spatial clustering, 216 Specificity, 154-156 Speech and language therapy, 105, 153 Spina bifida, 105,254 Spirilla, 188 Spirochetes, 188 Spontaneous abortion, 124 Spores, 189,211-212,322 Sporozoa, 197,201,212 Sporozoites, 237 Spousal abuse, 36,114-115 Standard of health, 335-336, 338 Standard of living, 73, 104, 129, 340 Standpipe (standpost), 167-168 Staphylococus aureus, 96, 189, 197,212

MRSA, 215, 316 State of the World's Children, 38 State of World Population, 38 Statistical significance, 47, 50, 58-59 Statistics (see Biostatistics) Stereocilia, 149 Sterilization, 122-123, 132-133 Stomach cancer, 116, 143-146 Stomach ulcers, 194, 198 Stillbirths, 88, 124, 370

and infection, 96, 198 Stove, 178 Strep throat (Streptococcus pyogenes) , 200 Stroke, 111, 140-142

and disability, 150-153 and hypertension, 28, 141 therapy, 153

Strongyloidiasis, 209 Structural adjustment, 288-289 Study designs

experimental, 50-52 observational,43-51 synthesis, 54-56

Stunting, 259

Subsistence farming, 67, 238 Sucrose, 250 Sufficient cause, 12 Sugar, 249-250

and diabetes, 148 and ORT/ORS, 94 vitamin A fortification, 264, 267

Suicide, 34-36, 70,110-111,114,116 Sulfadoxone/pyrimethamine, 240 Sulfur, 254 Sulfur oxides, 178, 182 Sun vitamin (see Vitamins) Superbugs (see Antimicrobial resistance) Supernatural theory of health, 82 Supplementation, 267

and children, 94-95, 97, 103,268,371 and pregnancy, 93, 121

Surveillance, 37, 62, 216, 363 Susceptibility, 192-193,318 Sustainability, 73, 129,326,345,

362-364,373 Swimming pools, 37, 196,206 Syndrome, 222 Syphilis, 93, 204

Tuskeegee Syphilis Experiment, 53 Systematic reviews, 42-43, 55-56

Taeniasis, 209 Tapeworm, 208-209, 210 Tartar siege of Kaffa, 322 Tay-Sachs Disease, 78 TB (see Tuberculosis) Technical assistance, 285, 295, 298 Telephone (see Communication

technologies) Temporal (time) clustering, 216 Teratogen, 180 Terrorist acts, 36, 322-325, 248 Tertiary prevention, 14-15 Tertiary research, 43 Tetanus, 198,212

children, 98 infants, 92-93 pregnancy, 121

Thiamine, 255, 263 Threadworm, 209 Throat cancer, 144

Thrush, 191, 224 Thyroid, 256, 265

cancer, 144, 180 hormones, 265

Ticks, 195, 200-202, 327 Tinea, 211

Index 401

Tobacco use, 26-28, 33, 310 Framework Convention on Tobacco

Control, 298, 363, 366 and lung disease, 148,231,370 taxes and policies, 369, 372-373

Toilet, 13, 174 Toxicology, 180-182 Toxocariasis, 209 Toxoplasmosis, 190,212,319 Trachoma, 116, 153,208-210,212,326

control initiatives, 244, 290, 370 Trade agreements, 342-343

Trade-Related Aspects of Intellectual Property Rights (TRIPS), 342-343

Traditional medicine (TM), 82-83 Traffic accidents, 34-36,110-111,114,

116,326 prevention of, 363, 370, 370

Trafficking (see Human trafficking) Trained birth attendant (TBA), 118-122 Trans fats, 252, 370 Transmissibility, 316 Transmission modes (see Modes of

transmission) Transnational health, 4 Transportation, 150-152, 197,318,355 Trash (see Waste management) Travel, 240-241, 243, 318 Trematodes, 190 Triatominae bugs (see Kissing bugs) Trichinosis (trichinellosis), 209 Trichomoniasis, 204-205 Trichuriasis, 205-209, 370 TRIPS, 342-343

TRIPS Plus, 342 Trypanosomiasis (African Sleeping

Sickness), 116, 195,201,203 control initiatives, 205, 244

Tsetse fly, 195,201,203 T-test,58 Tubal ligation, 122-123

402 INDEX

Tuberculosis (TB) diagnostic tests, 235 disease (active TB), 193,200,231 DOTS (directly observed therapy), 234 global health initiatives, 236 HIV co-infection, 231-234 incidence/prevalence, 116, 222,

231-234 infection (latent TB), 193,231 MDR-TB, 81, 231, 235 prevention, 235-236 prisons, 81 risk factors, 231 transmission, 194 treatment, 234-236 vaccine (BCG), 98, 235 in young adults, 11 0-111

Tube wells, 167, 182-183 Tularemia, 202, 323 Tuskegee syphilis experiment, 53 2X2 table, 45--46, 59, 52 Type I error, 58 Type 2 diabetes, 148 Type II error, 58 Typhoid fever, 98,197-198 Typhus fever, 195,200-202,323

Ulcers diabetic, 15, 148 Mycobacterium ulcerans, 210 stomach, 194, 198

Ultraviolet (UV) radiation, 165,328-329 UN (see United Nations) UNAIDS (Joint United Nations

Programme on AIDS), 299 Underemployment, 70 Under-5 children, 87

common infections, 88-98 global health initiatives, 101-104 under-5 clinics, 102 under-5 mortality, 87-88

Undernutrition, 9, 257-260, 263-268 Underweight, 257-260 Undulant fever (see Brucellosis) Unemployment, 69-70 UNFPA, 38,128,299 UN-HABITAT, 299

UNICEF (United Nations Children's Fund) annual report, 38 child health initiatives, 102 child protection, 106 humanitarian assistance, 295,

298-299, 354 infectious disease partnerships, 242, 244 well-digging interventions, 182-183

Unintentional injury, 34-37, 113-114 UNITAID,302 United Nations (UN), 38, 209-299

General Assembly, 104, 298 UN Development Programme (UNDP),

38,299,354 UN Environment Programme (UNEP),

184,299 UN Foundation, 289 UN High Commissioner for Refugees

(UNHCR), 299, 350-351, 354 UN Population Fund (UNFPA), 38,

128,299 UN Security Council, 298

United States of America (USA) (featured throughout book)

aging, 139, 158 causes of death, 5-6, 29, 139-140 charitable giving, 291-293 DALYs,30 economic status, 67, 75-76, 281-284 emergency management, 355 environment and health, 130, 171-l73,

l76-177, 314 food imports, 319 food insecurity, 260-262 foreign aid, 285-286, 289, 300-301 Gini Index, 75 health insurance, 278-280, 338 health system, 112,278-284,338,

341,345 infant and child mortality, 88, 92 infections, 234 injuries, 36 life expectancy, 22-23, 113 NCDs, 34, 141, 144, 147, 149 nutritional status, 264, 266, 270-272 popUlation pyramid, 139, 157 prisons, 80-81

public health agencies, 296 racial/ethnic categories, 78 reproductive health, 118-120,

124-125, 131 risk behaviors, 27 Vi!CCm~ rc~omn::II:;nilati.ons, 98

water rights, 347 Universal Declaration of Human Rights,

335-337,340 Universal health care, 278-279, 339 Universal precautions, 228, 230 Unmodifiable risk factors, 10 Unplanned urbanization, 310-312 Unsafe sex, 26, 165,230 Unsaturated fatty acids, 252 Unskilled workers, 69, 179-180 Upper respiratory infections, 96, 198 Urban health, 66,163,260,310-314

and utilities, 171, 174-176, 177 Urbanicity,310 Urbanization, 166,312-314,327 USAID (United States Agency for

International Development), 300-301, 305

Vaccination (see Immunization) Vaginal yeast infection (see Yeast) Validity, 60-61, 154-155 Valley fever, 199 Varicella, 98, 211 Vasectomy, 122-123 Vector, 195

control, 183-184,213,325 Vectorborne transmission, 195-196,

200-204 Ventilation, 178, 231 Ventilation-improved pit (VIP) latrine, 172 Vertical public health initiatives, 102 Vertical transmission, 195,205,229 Veterans Administration (VA), 279

Vibrios, 188 Vinyl chloride, 181,324 Violence, 34-36,110-111,114-116

and vulnerable populations, 78-80, 104-106,113-115,304

Viral meningitis, 212

Virulence, 193-194,316

Viruses, 189-190 and antibiotics, 96

Index 403

and dian'heal infections, 91, 198,319 HIV,221-222 influenza, 242-243 and respiratory infections, 198-200 and STIs, 205 and vectorbome infections, 202

Visceral leishmaniasis, 201, 203 Visual impairment, 148-149 Vital statistics, 21 Vitamin A deficiency (V AD), 264-265

and neonates, 93 and nutrition interventions, 97, 103,

264-265,267 and pregnancy, 264-265, 268, 372 and under-5 children, 95,102,264-265,

268,371-372 Vitamins, 28, 31, 254-255

biotin, 255 folate, 254-255 niacin, 255, 263 pantothenic acid, 255 pyridoxine, 255 riboflavin, 2552, 63 supplementation, 93-95, 121,254,265,

267-268,371 thiamine, 255, 263 vitamin A, 102, 255, 264-265 vitamin B 12, 255 vitamin e, 254, 263, 267 vitamin D, 254-255, 263 vitamin E, 255 vitamin K, 255

Voluntary organization (see Nongovernmental organization)

Volunteer bias, 59 Volunteering in global health, 16,244,

290-291,295 importance of local partners, 297,

352-355 organizations, 292-293

Waist circumference, 257 VVar,34-36, 114, 116,348-352

IeRe, 304-305 malnutrition, 350

404 INDEX

War (continued) malthusian catastrophes, 129-130 migration, 349-351 outbreaks, 350 sexual violence, 350

Warts, 204-205 Waste management, 163-164,311,325

and sanitation, 172-177 Wasting, 259 Water, 167-172

access, 168-172,311,346-347 cost, 168 and disasters, 347 fleas, 205 and nutrition, 282 ownership, 346-347 privatization, 346-347 proximity, 168-169 quality, 167 quantity, 168-169,346 reliability, 168 resources management, 325-326,

346-347 rights, 346-347 scarcity, 168-173,347 sources, 167 transmission 195

Water filters, 183,205-206,208 Wealth, 65-67 Weather extremes, 328-329 Weekly Epidemiological Record, 38 Weight-for-age,257-258 Weight-for-height, 257, 259 Wellcome Trust, 298, 366 Wells, 167-168, 171,346 West Nile virus, 195,202,317 Whipworm, 206-209, 267 Whitehall Cohort Study, 48 WHO (see World Health Organization)

Whooping cough, 98, 199-200 Wood,68,176-178 Workforce development, 3, 277, 305,

339-341 World B<mk, 38, 102,287-298,346 World Development Report, 38 World Food Program (WFP), 299, 354 World Health Assembly, 100,298 World Health Organization (WHO),

298-299 child health initiatives, 101-102 constitution, 1-2,335-336 growth standards, 257-258 health infonnation, 37-38, 43 health system building blocks, 277 HIV classification system, 223-224

World Health Statisitcs, 38 World Intellectual Property Organization

(WIPO),342 World Trade Organization (WTO), 342-343 World Vision, 290-292, 303 Worms (see Helminths) Wound healing, 256

Xerophthalmia, 264

Years of life lost (YLLs), 25 Years of life with disability (YLDs), 25 Yeast, 191,211 Yellow fever, 4, 98, 202 Yin and yang, 82

Zidovudine (AZT), 229 Zinc, 256, 267

and supplementation, 94, 95, 97, 103 Zithromax, 290 L.,UL'UU~l~, 195-196

and environmental change, 327, 329 Z-score, 258